| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,958 |
3,952 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
5,062 |
5,053 |
$103K |
| D0274 |
Bitewings - four radiographic images |
3,745 |
3,745 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
5,015 |
5,005 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,412 |
5,355 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,398 |
1,397 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
250 |
192 |
$11K |
| D1120 |
Prophylaxis - child |
262 |
262 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
78 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$672.28 |