| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
150 |
150 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
117 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,253 |
353 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
283 |
280 |
$3K |
| D1206 |
Topical application of fluoride varnish |
99 |
99 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
80 |
77 |
$1K |
| D0272 |
Bitewings - two radiographic images |
111 |
110 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$810.00 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$669.60 |