| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,619 |
1,613 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,227 |
2,220 |
$53K |
| D1120 |
Prophylaxis - child |
885 |
880 |
$31K |
| D0274 |
Bitewings - four radiographic images |
570 |
568 |
$17K |
| D1206 |
Topical application of fluoride varnish |
702 |
700 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$412.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$288.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
12 |
$111.00 |