| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,503 |
3,493 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
3,762 |
3,750 |
$72K |
| D0274 |
Bitewings - four radiographic images |
2,902 |
2,901 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
791 |
601 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
3,610 |
3,582 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
397 |
317 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,189 |
3,185 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
270 |
270 |
$8K |
| D1320 |
|
716 |
716 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
79 |
$734.39 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$133.20 |