| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
342 |
342 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
579 |
578 |
$17K |
| D9430 |
|
427 |
383 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
265 |
$13K |
| D1120 |
Prophylaxis - child |
347 |
345 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
774 |
771 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
177 |
$7K |
| D0274 |
Bitewings - four radiographic images |
281 |
280 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
45 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
377 |
361 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
438 |
238 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
32 |
$737.50 |