| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,747 |
2,747 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,358 |
3,358 |
$68K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,290 |
3,288 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
2,393 |
2,377 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
3,343 |
3,328 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
144 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
823 |
823 |
$9K |
| D1120 |
Prophylaxis - child |
305 |
305 |
$9K |
| D0274 |
Bitewings - four radiographic images |
358 |
358 |
$7K |
| D2750 |
|
13 |
13 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
34 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
87 |
87 |
$842.04 |