| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,458 |
1,458 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,434 |
1,434 |
$32K |
| D0274 |
Bitewings - four radiographic images |
444 |
444 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
838 |
829 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
565 |
561 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
121 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$520.56 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$314.16 |
| D1999 |
|
19 |
18 |
$0.00 |