| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
534 |
523 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
752 |
740 |
$25K |
| D1206 |
Topical application of fluoride varnish |
734 |
723 |
$24K |
| D1120 |
Prophylaxis - child |
490 |
480 |
$16K |
| D0274 |
Bitewings - four radiographic images |
288 |
277 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
124 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
12 |
$341.20 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$292.50 |
| D9986 |
|
13 |
13 |
$0.00 |