| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,286 |
2,285 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,775 |
2,771 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,057 |
3,046 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
3,268 |
3,218 |
$29K |
| D1120 |
Prophylaxis - child |
654 |
652 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,502 |
1,502 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
107 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,169 |
1,167 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,020 |
1,018 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$207.44 |