| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
335 |
307 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
692 |
644 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$943.73 |
| D1120 |
Prophylaxis - child |
351 |
334 |
$879.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$849.51 |
| D1208 |
Topical application of fluoride, excluding varnish |
631 |
604 |
$141.00 |
| D0274 |
Bitewings - four radiographic images |
189 |
179 |
$116.35 |
| D1330 |
|
798 |
750 |
$54.00 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$21.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
37 |
$0.00 |