| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,705 |
1,677 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,072 |
1,062 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
1,204 |
1,189 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,893 |
2,202 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,645 |
1,612 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
564 |
563 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
85 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,999 |
1,962 |
$2K |
| D2335 |
|
42 |
13 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$909.00 |
| D1120 |
Prophylaxis - child |
127 |
127 |
$461.50 |
| D2332 |
|
46 |
13 |
$230.25 |
| D0350 |
|
19 |
19 |
$68.00 |
| D1999 |
|
203 |
203 |
$0.00 |