| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,202 |
1,200 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,831 |
1,829 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
95 |
93 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
334 |
333 |
$3K |
| D1120 |
Prophylaxis - child |
96 |
96 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
171 |
$1K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
69 |
$737.85 |
| D9991 |
|
34 |
34 |
$25.00 |
| D1999 |
|
62 |
62 |
$0.00 |