| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,203 |
1,203 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,318 |
1,317 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,816 |
1,805 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,288 |
1,278 |
$11K |
| D0274 |
Bitewings - four radiographic images |
262 |
262 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$687.64 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$329.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$132.90 |