| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
729 |
633 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
948 |
823 |
$24K |
| D0272 |
Bitewings - two radiographic images |
488 |
414 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
61 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
98 |
79 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
140 |
105 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
25 |
$541.30 |
| D1206 |
Topical application of fluoride varnish |
27 |
13 |
$518.70 |
| D0602 |
|
27 |
27 |
$135.00 |