| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,991 |
2,991 |
$148K |
| D0120 |
Periodic oral evaluation - established patient |
4,048 |
4,048 |
$104K |
| D0274 |
Bitewings - four radiographic images |
1,466 |
1,466 |
$38K |
| D1120 |
Prophylaxis - child |
992 |
992 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
1,889 |
1,880 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,529 |
1,529 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
379 |
379 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
84 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
910 |
903 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
50 |
$4K |
| D9110 |
|
88 |
88 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$859.25 |
| D1999 |
|
13 |
13 |
$0.00 |