| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
265 |
256 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
358 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
199 |
185 |
$2K |
| D1120 |
Prophylaxis - child |
136 |
129 |
$2K |
| D0274 |
Bitewings - four radiographic images |
164 |
161 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
34 |
$0.00 |