| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
906 |
820 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,389 |
1,260 |
$53K |
| D1206 |
Topical application of fluoride varnish |
1,535 |
1,362 |
$46K |
| D0274 |
Bitewings - four radiographic images |
297 |
259 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
38 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
51 |
$11K |
| D1120 |
Prophylaxis - child |
228 |
205 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
13 |
$686.25 |
| D0603 |
|
507 |
427 |
$0.00 |
| D0602 |
|
196 |
168 |
$0.00 |