| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,617 |
1,613 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,188 |
2,185 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,507 |
1,504 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,746 |
1,708 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,615 |
1,610 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
1,246 |
1,240 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
266 |
266 |
$3K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$858.60 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$570.24 |