| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,211 |
1,211 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,905 |
1,905 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
323 |
198 |
$34K |
| D1120 |
Prophylaxis - child |
753 |
753 |
$25K |
| D1206 |
Topical application of fluoride varnish |
662 |
662 |
$14K |
| D0274 |
Bitewings - four radiographic images |
359 |
359 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
72 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$3K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$175.00 |