| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,000 |
2,000 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,271 |
2,271 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,229 |
1,229 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,573 |
1,567 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,486 |
1,481 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
412 |
412 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
42 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
91 |
$4K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$939.66 |