| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,275 |
2,274 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
3,437 |
3,426 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,349 |
2,342 |
$473.72 |
| D0274 |
Bitewings - four radiographic images |
2,054 |
2,051 |
$382.17 |
| D1120 |
Prophylaxis - child |
864 |
864 |
$326.80 |
| D0220 |
Intraoral - periapical first radiographic image |
2,465 |
2,454 |
$236.85 |
| D0140 |
Limited oral evaluation - problem focused |
130 |
124 |
$181.45 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
247 |
189 |
$170.17 |
| D0210 |
Intraoral - complete series of radiographic images |
949 |
946 |
$74.93 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
24 |
$62.83 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,760 |
1,760 |
$0.00 |