| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,929 |
2,929 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
2,898 |
2,898 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,916 |
1,916 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
3,089 |
3,070 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,582 |
2,580 |
$22K |
| D9110 |
|
685 |
684 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
470 |
468 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
227 |
227 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
28 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$770.62 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$384.00 |
| D1999 |
|
137 |
126 |
$0.00 |