| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
747 |
732 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
915 |
900 |
$22K |
| D0274 |
Bitewings - four radiographic images |
536 |
525 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
726 |
714 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
498 |
480 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
110 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$982.00 |
| D1120 |
Prophylaxis - child |
28 |
28 |
$865.25 |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$768.25 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$340.90 |
| D1330 |
|
830 |
814 |
$0.00 |
| D1999 |
|
89 |
81 |
$0.00 |