| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
475 |
475 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
262 |
262 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
483 |
482 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
268 |
$8K |
| D1120 |
Prophylaxis - child |
99 |
97 |
$4K |
| D0274 |
Bitewings - four radiographic images |
92 |
92 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
119 |
118 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
133 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$264.00 |