| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,091 |
1,980 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
3,461 |
3,263 |
$67K |
| D1206 |
Topical application of fluoride varnish |
2,370 |
2,201 |
$41K |
| D1120 |
Prophylaxis - child |
1,397 |
1,290 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,207 |
1,113 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
245 |
146 |
$13K |
| D0272 |
Bitewings - two radiographic images |
199 |
164 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
119 |
$3K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$371.35 |
| D0603 |
|
12 |
12 |
$60.00 |
| D1999 |
|
53 |
51 |
$0.00 |