| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,853 |
1,853 |
$92K |
| D0274 |
Bitewings - four radiographic images |
1,814 |
1,814 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,326 |
1,326 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
579 |
579 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,188 |
1,124 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
652 |
652 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
64 |
$9K |
| D1120 |
Prophylaxis - child |
103 |
103 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$876.40 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$227.28 |