| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
927 |
927 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
1,041 |
1,038 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
920 |
920 |
$19K |
| D1120 |
Prophylaxis - child |
338 |
338 |
$10K |
| D0272 |
Bitewings - two radiographic images |
872 |
872 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
374 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
104 |
63 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
635 |
635 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
66 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
72 |
$974.60 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$337.88 |