| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
275 |
268 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
427 |
411 |
$9K |
| D1110 |
Prophylaxis - adult |
205 |
196 |
$8K |
| D0274 |
Bitewings - four radiographic images |
250 |
239 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
59 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
58 |
$4K |
| D1206 |
Topical application of fluoride varnish |
276 |
268 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
122 |
118 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
35 |
$922.35 |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
58 |
$479.91 |
| D9986 |
|
16 |
16 |
$9.00 |