| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
564 |
558 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
662 |
661 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
427 |
423 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
413 |
408 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,192 |
1,178 |
$15K |
| D1120 |
Prophylaxis - child |
379 |
379 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
884 |
485 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
36 |
$6K |
| D0274 |
Bitewings - four radiographic images |
119 |
118 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |