| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
443 |
429 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
558 |
541 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
58 |
$6K |
| D0272 |
Bitewings - two radiographic images |
327 |
317 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
364 |
353 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$800.28 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
60 |
$565.24 |