| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
871 |
871 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,200 |
1,200 |
$23K |
| D0274 |
Bitewings - four radiographic images |
492 |
492 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
382 |
381 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
51 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
285 |
285 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$655.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$138.25 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$55.50 |
| D1330 |
|
16 |
16 |
$0.00 |