| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
485 |
483 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
401 |
399 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
354 |
354 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,144 |
1,133 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
283 |
283 |
$13K |
| D4910 |
|
107 |
105 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,237 |
430 |
$5K |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$4K |
| D9430 |
|
92 |
88 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
14 |
$192.00 |