| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
646 |
632 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
432 |
425 |
$5K |
| D1110 |
Prophylaxis - adult |
107 |
107 |
$5K |
| D1120 |
Prophylaxis - child |
147 |
147 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
112 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
436 |
381 |
$3K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
348 |
141 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
56 |
$2K |
| D9920 |
|
30 |
24 |
$1K |
| D2394 |
|
35 |
13 |
$0.00 |
| D9610 |
|
13 |
13 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
29 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
25 |
$0.00 |
| D9994 |
|
81 |
81 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
50 |
26 |
$0.00 |