| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,488 |
1,484 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,911 |
1,909 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,194 |
1,194 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
169 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
221 |
180 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,156 |
1,156 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,297 |
1,297 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
189 |
189 |
$2K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$742.40 |
| D1999 |
|
19 |
19 |
$0.00 |