| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,230 |
1,230 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
2,085 |
2,085 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
118 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
812 |
812 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
85 |
$9K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$3K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$746.12 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
42 |
$541.49 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$455.28 |