| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,081 |
2,078 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
2,314 |
2,309 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,552 |
2,543 |
$12K |
| D0272 |
Bitewings - two radiographic images |
2,030 |
2,025 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,365 |
2,314 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
67 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
203 |
203 |
$3K |
| D0274 |
Bitewings - four radiographic images |
175 |
174 |
$1K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
108 |
$691.58 |
| D0601 |
|
26 |
26 |
$25.00 |