| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
641 |
603 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
247 |
236 |
$6K |
| D2950 |
|
24 |
13 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
79 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
28 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
28 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$565.00 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$476.00 |