| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
359 |
357 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
460 |
456 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
393 |
391 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,703 |
424 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
78 |
$6K |
| D9430 |
|
147 |
142 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
284 |
284 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
27 |
$3K |
| D1206 |
Topical application of fluoride varnish |
187 |
187 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
19 |
$2K |
| D0274 |
Bitewings - four radiographic images |
77 |
76 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$165.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$132.00 |