| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,026 |
2,026 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,642 |
1,642 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,210 |
1,210 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
544 |
544 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,592 |
1,581 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,412 |
1,409 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
276 |
276 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
24 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$193.10 |