| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,180 |
2,180 |
$79K |
| D0274 |
Bitewings - four radiographic images |
2,011 |
2,011 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,356 |
1,355 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,169 |
2,169 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
883 |
883 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,162 |
2,162 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
339 |
339 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
24 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$383.34 |