| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
843 |
843 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,588 |
1,588 |
$19K |
| D0274 |
Bitewings - four radiographic images |
546 |
546 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,137 |
1,131 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,445 |
1,437 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$583.52 |
| D0140 |
Limited oral evaluation - problem focused |
131 |
130 |
$529.08 |
| D1120 |
Prophylaxis - child |
98 |
98 |
$514.68 |
| D0272 |
Bitewings - two radiographic images |
80 |
80 |
$59.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
82 |
82 |
$28.00 |