| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
804 |
761 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,149 |
1,083 |
$27K |
| D1206 |
Topical application of fluoride varnish |
442 |
426 |
$7K |
| D0274 |
Bitewings - four radiographic images |
205 |
203 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$2K |
| D1120 |
Prophylaxis - child |
60 |
59 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$732.16 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$581.74 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$228.67 |