| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,302 |
1,302 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,868 |
1,868 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,528 |
1,528 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,754 |
1,741 |
$18K |
| D1120 |
Prophylaxis - child |
309 |
309 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
76 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
333 |
333 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
40 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
389 |
387 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$125.48 |