| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
420 |
417 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
288 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
283 |
283 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,587 |
993 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$2K |
| D0272 |
Bitewings - two radiographic images |
164 |
164 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$808.80 |
| D9430 |
|
15 |
15 |
$480.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$214.50 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$144.00 |