| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,007 |
983 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
913 |
899 |
$12K |
| D0274 |
Bitewings - four radiographic images |
498 |
490 |
$10K |
| D1206 |
Topical application of fluoride varnish |
433 |
433 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
791 |
624 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
482 |
387 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
26 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
66 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$0.00 |