| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,780 |
2,779 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
2,633 |
2,632 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,076 |
2,076 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,446 |
2,427 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,250 |
2,247 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
531 |
531 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
145 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
759 |
759 |
$9K |
| D1120 |
Prophylaxis - child |
128 |
128 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$145.97 |