| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
610 |
509 |
$28K |
| D0274 |
Bitewings - four radiographic images |
448 |
370 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
409 |
364 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
202 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
38 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
561 |
442 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
177 |
142 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
327 |
149 |
$2K |
| D1206 |
Topical application of fluoride varnish |
119 |
109 |
$2K |
| D1120 |
Prophylaxis - child |
15 |
13 |
$207.00 |
| D1999 |
|
464 |
342 |
$0.00 |