| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
729 |
654 |
$30K |
| D0274 |
Bitewings - four radiographic images |
513 |
462 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
389 |
370 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
973 |
463 |
$9K |
| D0350 |
|
343 |
327 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
210 |
155 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
543 |
490 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
38 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
13 |
$3K |
| D1320 |
|
147 |
138 |
$2K |
| D1321 |
|
147 |
138 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
49 |
$1K |
| D1206 |
Topical application of fluoride varnish |
21 |
15 |
$180.00 |