| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,112 |
773 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
996 |
714 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
52 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
148 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
126 |
$8K |
| D0274 |
Bitewings - four radiographic images |
397 |
265 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
15 |
$211.20 |