| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
381 |
377 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
586 |
583 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
453 |
447 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
392 |
388 |
$18K |
| D1206 |
Topical application of fluoride varnish |
892 |
885 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,676 |
880 |
$11K |
| D0274 |
Bitewings - four radiographic images |
521 |
516 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
66 |
$9K |
| D1120 |
Prophylaxis - child |
227 |
223 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
36 |
$4K |
| D4341 |
|
51 |
14 |
$4K |
| D9430 |
|
40 |
36 |
$1K |
| D4910 |
|
15 |
15 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$168.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |