| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
428 |
412 |
$21K |
| D1206 |
Topical application of fluoride varnish |
742 |
721 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
552 |
538 |
$13K |
| D0274 |
Bitewings - four radiographic images |
371 |
357 |
$13K |
| D1120 |
Prophylaxis - child |
202 |
201 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
29 |
$7K |
| D1320 |
|
39 |
39 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
29 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$945.84 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
25 |
$916.09 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$779.30 |
| D1330 |
|
14 |
14 |
$216.68 |