| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
414 |
387 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
398 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
124 |
$1K |
| D0274 |
Bitewings - four radiographic images |
192 |
182 |
$1K |
| D1206 |
Topical application of fluoride varnish |
219 |
191 |
$298.61 |
| D1120 |
Prophylaxis - child |
60 |
54 |
$273.42 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
74 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
39 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
25 |
$0.00 |
| D0330 |
Panoramic radiographic image |
30 |
21 |
$0.00 |