| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,303 |
2,299 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,677 |
2,671 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
3,623 |
3,599 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,586 |
1,586 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,153 |
3,138 |
$16K |
| D1120 |
Prophylaxis - child |
551 |
551 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
652 |
650 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
149 |
121 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
673 |
672 |
$8K |
| D0272 |
Bitewings - two radiographic images |
599 |
599 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
64 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
170 |
$1K |
| D0270 |
|
29 |
29 |
$101.75 |