| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,139 |
2,139 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,193 |
1,006 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
2,681 |
2,678 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
999 |
886 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,902 |
1,901 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,310 |
2,305 |
$25K |
| D1120 |
Prophylaxis - child |
656 |
656 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
534 |
532 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,073 |
2,073 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
867 |
867 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$2K |
| D9110 |
|
27 |
26 |
$577.77 |
| D1999 |
|
98 |
88 |
$0.00 |