| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
680 |
675 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
348 |
170 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
940 |
932 |
$26K |
| D0274 |
Bitewings - four radiographic images |
663 |
660 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
813 |
809 |
$12K |
| D1120 |
Prophylaxis - child |
287 |
283 |
$10K |
| D7240 |
Removal of impacted tooth - completely bony |
38 |
13 |
$6K |
| D0330 |
Panoramic radiographic image |
204 |
203 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
28 |
$4K |
| D0272 |
Bitewings - two radiographic images |
165 |
163 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$1K |
| D1206 |
Topical application of fluoride varnish |
31 |
28 |
$351.33 |
| D0603 |
|
1,311 |
1,302 |
$0.00 |