| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,140 |
2,139 |
$74K |
| D0274 |
Bitewings - four radiographic images |
2,015 |
2,014 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,628 |
1,628 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
3,103 |
3,083 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
342 |
282 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,843 |
2,833 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
806 |
806 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
781 |
772 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
296 |
287 |
$3K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$720.32 |
| D4341 |
|
22 |
12 |
$712.50 |
| D0270 |
|
40 |
40 |
$361.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$341.05 |