| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,190 |
1,172 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
454 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
546 |
546 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,429 |
1,415 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
134 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
364 |
364 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,784 |
919 |
$11K |
| D9430 |
|
351 |
326 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
116 |
70 |
$9K |
| D0274 |
Bitewings - four radiographic images |
280 |
277 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
40 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
273 |
$3K |
| D2394 |
|
22 |
14 |
$2K |