| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,070 |
1,067 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
309 |
162 |
$17K |
| D1120 |
Prophylaxis - child |
146 |
146 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
59 |
$1K |
| D0274 |
Bitewings - four radiographic images |
675 |
673 |
$735.28 |
| D0120 |
Periodic oral evaluation - established patient |
1,597 |
1,593 |
$455.22 |
| D1206 |
Topical application of fluoride varnish |
901 |
899 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
69 |
$0.00 |