| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,157 |
1,156 |
$118K |
| D1120 |
Prophylaxis - child |
402 |
402 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
67 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
338 |
338 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,032 |
1,032 |
$961.75 |
| D0120 |
Periodic oral evaluation - established patient |
1,503 |
1,502 |
$425.62 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$263.30 |
| D0220 |
Intraoral - periapical first radiographic image |
1,870 |
1,848 |
$193.52 |
| D1206 |
Topical application of fluoride varnish |
1,572 |
1,572 |
$138.67 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,011 |
1,699 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
202 |
202 |
$0.00 |