| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,229 |
2,229 |
$80K |
| D0274 |
Bitewings - four radiographic images |
1,868 |
1,866 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,621 |
1,620 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,813 |
1,806 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,888 |
1,879 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
719 |
719 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
232 |
153 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
50 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
275 |
273 |
$4K |
| D0330 |
Panoramic radiographic image |
81 |
81 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$479.60 |
| D1999 |
|
287 |
269 |
$0.00 |