| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
437 |
437 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
680 |
680 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
343 |
219 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
376 |
$19K |
| D1120 |
Prophylaxis - child |
553 |
553 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
138 |
$12K |
| D0274 |
Bitewings - four radiographic images |
561 |
560 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,069 |
1,069 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
252 |
252 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,958 |
878 |
$7K |
| D9430 |
|
84 |
76 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
199 |
195 |
$2K |
| D4910 |
|
25 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$160.00 |