| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,254 |
1,253 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,507 |
1,506 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,428 |
1,426 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,602 |
1,598 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
268 |
160 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,297 |
1,281 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
76 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
150 |
150 |
$1K |
| D1120 |
Prophylaxis - child |
16 |
16 |
$309.22 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$211.61 |