| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
807 |
750 |
$25K |
| D1206 |
Topical application of fluoride varnish |
742 |
681 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,415 |
1,305 |
$22K |
| D0240 |
|
386 |
348 |
$18K |
| D1120 |
Prophylaxis - child |
364 |
330 |
$15K |
| D0274 |
Bitewings - four radiographic images |
390 |
370 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
458 |
428 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
630 |
590 |
$6K |
| D1310 |
|
198 |
156 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
586 |
474 |
$4K |
| D1330 |
|
199 |
157 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
96 |
$2K |
| D1999 |
|
14 |
14 |
$0.00 |