| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
566 |
546 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,033 |
893 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
565 |
551 |
$8K |
| D1206 |
Topical application of fluoride varnish |
509 |
503 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
28 |
$6K |
| D0274 |
Bitewings - four radiographic images |
270 |
258 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
62 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
436 |
400 |
$4K |
| D9630 |
|
87 |
87 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
56 |
$626.20 |