| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
770 |
736 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,304 |
1,254 |
$19K |
| D0274 |
Bitewings - four radiographic images |
180 |
175 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
483 |
464 |
$2K |
| D1206 |
Topical application of fluoride varnish |
120 |
119 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
392 |
341 |
$2K |
| D1120 |
Prophylaxis - child |
74 |
70 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$972.99 |
| D0140 |
Limited oral evaluation - problem focused |
47 |
46 |
$903.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$675.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |
| D1999 |
|
22 |
19 |
$0.00 |