| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,545 |
1,435 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,116 |
2,013 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,799 |
1,685 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
409 |
191 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,282 |
1,211 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
677 |
623 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
190 |
177 |
$8K |
| D1120 |
Prophylaxis - child |
160 |
155 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
47 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
316 |
62 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$3K |
| D1330 |
|
15 |
15 |
$170.66 |