| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,392 |
2,392 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,413 |
2,413 |
$42K |
| D0274 |
Bitewings - four radiographic images |
2,375 |
2,375 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,438 |
2,438 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,046 |
1,045 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
526 |
526 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
42 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
24 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$858.91 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$766.96 |
| D9110 |
|
12 |
12 |
$226.69 |
| D1999 |
|
13 |
12 |
$0.00 |