| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
179 |
175 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
363 |
358 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
180 |
$4K |
| D1120 |
Prophylaxis - child |
270 |
267 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,285 |
1,146 |
$2K |
| D0272 |
Bitewings - two radiographic images |
929 |
912 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
271 |
268 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,195 |
992 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$527.40 |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$100.80 |
| D1330 |
|
167 |
166 |
$0.00 |