| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,983 |
1,982 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,316 |
2,316 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,356 |
1,355 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,993 |
1,989 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
411 |
411 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
160 |
$13K |
| D1206 |
Topical application of fluoride varnish |
457 |
457 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
207 |
$12K |
| D1120 |
Prophylaxis - child |
308 |
308 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
657 |
657 |
$8K |
| D0272 |
Bitewings - two radiographic images |
258 |
258 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
194 |
192 |
$2K |
| D1310 |
|
13 |
13 |
$0.00 |
| D1330 |
|
13 |
13 |
$0.00 |