| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,293 |
1,293 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,453 |
1,452 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,126 |
1,120 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,419 |
1,407 |
$17K |
| D0274 |
Bitewings - four radiographic images |
252 |
252 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
239 |
235 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$674.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$156.00 |