| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
918 |
911 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
1,081 |
1,081 |
$54K |
| D1120 |
Prophylaxis - child |
937 |
937 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,331 |
1,325 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,359 |
1,964 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
906 |
906 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
67 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
120 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
71 |
$3K |
| D4341 |
|
48 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$414.00 |