| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
951 |
944 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
1,239 |
1,238 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,416 |
2,008 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
516 |
229 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,598 |
1,596 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
324 |
323 |
$18K |
| D9430 |
|
534 |
521 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,234 |
1,229 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
277 |
276 |
$12K |
| D1120 |
Prophylaxis - child |
302 |
301 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
65 |
$681.00 |
| D1206 |
Topical application of fluoride varnish |
65 |
65 |
$574.00 |
| D1330 |
|
1,699 |
1,694 |
$0.00 |