| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,483 |
1,477 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,305 |
1,299 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
266 |
266 |
$6K |
| D2752 |
|
14 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
843 |
826 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
258 |
$2K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
336 |
332 |
$976.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$841.20 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$450.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$300.00 |