| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,001 |
1,000 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,171 |
1,171 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
778 |
778 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,218 |
1,213 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
918 |
917 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
278 |
278 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$894.40 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$539.16 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$360.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$270.06 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$145.60 |
| D1999 |
|
239 |
237 |
$0.00 |
| D0707 |
|
13 |
12 |
$0.00 |