| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,503 |
4,500 |
$273K |
| D0120 |
Periodic oral evaluation - established patient |
4,305 |
4,303 |
$131K |
| D0274 |
Bitewings - four radiographic images |
1,850 |
1,849 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
520 |
402 |
$48K |
| D0330 |
Panoramic radiographic image |
286 |
286 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
717 |
712 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
311 |
311 |
$10K |
| D1120 |
Prophylaxis - child |
76 |
76 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
200 |
200 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
33 |
$892.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
65 |
$743.19 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$615.55 |
| D1999 |
|
117 |
112 |
$0.00 |