| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,589 |
1,588 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,970 |
1,969 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,665 |
1,665 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,996 |
1,991 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
202 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,807 |
1,807 |
$8K |
| D2332 |
|
19 |
13 |
$4K |
| D2335 |
|
15 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$751.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$395.40 |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$386.68 |