| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
285 |
277 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
321 |
314 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
299 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,242 |
650 |
$13K |
| D0274 |
Bitewings - four radiographic images |
521 |
513 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
650 |
639 |
$10K |
| D0350 |
|
655 |
173 |
$6K |
| D1120 |
Prophylaxis - child |
66 |
65 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
25 |
$3K |
| D9430 |
|
24 |
24 |
$768.00 |