| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
924 |
896 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
931 |
904 |
$21K |
| D0274 |
Bitewings - four radiographic images |
142 |
135 |
$5K |
| D1206 |
Topical application of fluoride varnish |
186 |
180 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
69 |
$835.71 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$492.74 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$128.60 |
| D1999 |
|
16 |
12 |
$0.00 |