| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,233 |
6,233 |
$287K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,705 |
1,218 |
$130K |
| D0120 |
Periodic oral evaluation - established patient |
5,610 |
5,610 |
$129K |
| D0210 |
Intraoral - complete series of radiographic images |
1,920 |
1,918 |
$87K |
| D0274 |
Bitewings - four radiographic images |
2,334 |
2,334 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,736 |
1,736 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
2,969 |
2,964 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,428 |
2,428 |
$14K |
| D1120 |
Prophylaxis - child |
402 |
402 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
272 |
226 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
224 |
224 |
$3K |
| D9110 |
|
73 |
73 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$891.10 |
| D1999 |
|
14 |
14 |
$0.00 |