| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,393 |
2,393 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
3,143 |
3,143 |
$64K |
| D0274 |
Bitewings - four radiographic images |
2,774 |
2,773 |
$55K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,902 |
2,896 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
516 |
236 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
78 |
$8K |
| D1120 |
Prophylaxis - child |
128 |
128 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
290 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
210 |
210 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
421 |
421 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$120.62 |