| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,399 |
1,229 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,484 |
2,154 |
$51K |
| D1206 |
Topical application of fluoride varnish |
782 |
646 |
$14K |
| D1120 |
Prophylaxis - child |
398 |
308 |
$10K |
| D0274 |
Bitewings - four radiographic images |
204 |
163 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
29 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
25 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
24 |
$771.76 |
| D0272 |
Bitewings - two radiographic images |
26 |
17 |
$262.50 |