| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,177 |
1,166 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,242 |
1,240 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,133 |
1,121 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
1,517 |
1,495 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,314 |
1,311 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
18 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
36 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$980.43 |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
69 |
$768.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$703.10 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$517.46 |