| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,431 |
1,430 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,989 |
1,986 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,737 |
1,733 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,132 |
2,118 |
$15K |
| D1120 |
Prophylaxis - child |
419 |
417 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,076 |
1,071 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
83 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
449 |
447 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
54 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
61 |
$735.81 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$135.98 |