| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
634 |
567 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
867 |
802 |
$19K |
| D1120 |
Prophylaxis - child |
222 |
210 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
686 |
635 |
$9K |
| D0274 |
Bitewings - four radiographic images |
402 |
359 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
141 |
72 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
162 |
92 |
$6K |
| D0330 |
Panoramic radiographic image |
114 |
109 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
75 |
65 |
$1K |
| D0272 |
Bitewings - two radiographic images |
65 |
59 |
$950.04 |
| D0602 |
|
18 |
16 |
$0.00 |