| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,526 |
1,376 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,794 |
1,713 |
$31K |
| D1120 |
Prophylaxis - child |
731 |
694 |
$23K |
| D0274 |
Bitewings - four radiographic images |
756 |
670 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
714 |
648 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
63 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
44 |
$7K |
| D0330 |
Panoramic radiographic image |
127 |
71 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
46 |
$2K |
| D0272 |
Bitewings - two radiographic images |
56 |
55 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$530.00 |
| D1206 |
Topical application of fluoride varnish |
38 |
26 |
$468.00 |