| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
571 |
494 |
$28K |
| D1206 |
Topical application of fluoride varnish |
856 |
736 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
690 |
578 |
$18K |
| D0274 |
Bitewings - four radiographic images |
340 |
295 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
25 |
$5K |
| D1120 |
Prophylaxis - child |
120 |
111 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
60 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$616.68 |
| D0272 |
Bitewings - two radiographic images |
14 |
12 |
$0.00 |