| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
431 |
430 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
241 |
241 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
374 |
373 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
435 |
433 |
$2K |
| D0274 |
Bitewings - four radiographic images |
130 |
130 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$561.60 |
| D0191 |
|
15 |
14 |
$375.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$273.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$71.50 |