| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
209 |
209 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
231 |
229 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
69 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
106 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
884 |
466 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
27 |
$3K |
| D0274 |
Bitewings - four radiographic images |
144 |
144 |
$3K |
| D0350 |
|
315 |
139 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
159 |
$2K |
| D9430 |
|
40 |
40 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$292.00 |
| D0270 |
|
31 |
29 |
$155.00 |