| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,238 |
3,236 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
5,666 |
5,664 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
5,900 |
5,890 |
$18K |
| D0274 |
Bitewings - four radiographic images |
2,079 |
2,079 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,800 |
3,789 |
$9K |
| D1120 |
Prophylaxis - child |
555 |
555 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
748 |
748 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
30 |
$1K |
| D0272 |
Bitewings - two radiographic images |
229 |
229 |
$947.58 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
24 |
$700.26 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
88 |
$577.83 |
| D0140 |
Limited oral evaluation - problem focused |
102 |
102 |
$497.43 |
| D0190 |
|
12 |
12 |
$0.00 |