| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,482 |
1,482 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,035 |
2,035 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,292 |
1,292 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,556 |
1,556 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,278 |
1,278 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
138 |
138 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$907.10 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$423.78 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$148.96 |