| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,778 |
2,778 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
3,976 |
3,973 |
$23K |
| D0274 |
Bitewings - four radiographic images |
2,077 |
2,072 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
4,499 |
4,474 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,577 |
3,564 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
282 |
187 |
$3K |
| D1120 |
Prophylaxis - child |
312 |
312 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
205 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
569 |
569 |
$1K |
| D0272 |
Bitewings - two radiographic images |
342 |
341 |
$774.53 |
| D0140 |
Limited oral evaluation - problem focused |
156 |
152 |
$550.35 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
25 |
$531.96 |
| D9310 |
|
12 |
12 |
$183.75 |