| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,672 |
1,672 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
2,113 |
2,111 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,896 |
1,896 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,687 |
2,671 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,321 |
2,319 |
$19K |
| D1120 |
Prophylaxis - child |
198 |
198 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
289 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
365 |
350 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
52 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
214 |
214 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$775.30 |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
117 |
$589.04 |
| D0270 |
|
12 |
12 |
$103.18 |
| D1999 |
|
12 |
12 |
$0.00 |