| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,539 |
1,538 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,656 |
1,655 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,682 |
1,638 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,694 |
1,693 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,003 |
1,003 |
$11K |
| D0274 |
Bitewings - four radiographic images |
150 |
150 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
13 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
86 |
$950.70 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$838.52 |
| D1120 |
Prophylaxis - child |
19 |
19 |
$595.64 |