| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
130 |
68 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
585 |
181 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
388 |
201 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
203 |
111 |
$1K |
| D1120 |
Prophylaxis - child |
138 |
69 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
118 |
62 |
$925.88 |
| D0220 |
Intraoral - periapical first radiographic image |
325 |
170 |
$877.14 |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
12 |
$781.44 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
31 |
$547.46 |
| D0272 |
Bitewings - two radiographic images |
31 |
16 |
$151.97 |
| D0603 |
|
454 |
242 |
$0.00 |