| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,067 |
1,064 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,209 |
1,209 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
1,005 |
1,005 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
533 |
531 |
$37K |
| D0350 |
|
2,023 |
533 |
$19K |
| D0274 |
Bitewings - four radiographic images |
695 |
692 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,497 |
918 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
53 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
36 |
36 |
$2K |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$388.50 |