| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,208 |
2,207 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,725 |
2,721 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,955 |
1,955 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
3,022 |
3,001 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,756 |
2,748 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
354 |
300 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
641 |
641 |
$7K |
| D1120 |
Prophylaxis - child |
197 |
197 |
$6K |
| D2330 |
|
84 |
75 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
190 |
182 |
$2K |
| D0272 |
Bitewings - two radiographic images |
144 |
144 |
$2K |
| D2140 |
|
36 |
28 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
134 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$683.96 |
| D1330 |
|
34 |
34 |
$0.00 |