| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,141 |
1,140 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,156 |
1,154 |
$21K |
| D0274 |
Bitewings - four radiographic images |
465 |
465 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
524 |
508 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
73 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
205 |
$2K |
| D1320 |
|
162 |
162 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
109 |
$422.77 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
13 |
$90.96 |