| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
766 |
741 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,042 |
1,006 |
$25K |
| D0274 |
Bitewings - four radiographic images |
238 |
232 |
$8K |
| D1320 |
|
180 |
171 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
24 |
$4K |
| D1206 |
Topical application of fluoride varnish |
193 |
191 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$906.66 |
| D9630 |
|
39 |
37 |
$646.88 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$525.90 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
26 |
$483.96 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$420.72 |