| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,715 |
2,708 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
2,889 |
2,885 |
$63K |
| D0274 |
Bitewings - four radiographic images |
1,154 |
1,154 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
286 |
234 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,607 |
1,606 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,495 |
1,493 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
127 |
127 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$119.08 |