| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
769 |
701 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,328 |
1,241 |
$27K |
| D1120 |
Prophylaxis - child |
930 |
884 |
$27K |
| D0274 |
Bitewings - four radiographic images |
732 |
683 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
209 |
105 |
$16K |
| D1206 |
Topical application of fluoride varnish |
929 |
864 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
163 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
35 |
$614.38 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$435.54 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$165.36 |
| D1999 |
|
13 |
13 |
$0.00 |
| D0601 |
|
112 |
109 |
$0.00 |