| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
440 |
429 |
$19K |
| D0274 |
Bitewings - four radiographic images |
286 |
281 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
317 |
304 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
31 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
138 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
16 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
51 |
$934.08 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$763.20 |