| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
573 |
572 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
779 |
778 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
33 |
$6K |
| D1120 |
Prophylaxis - child |
94 |
94 |
$4K |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
22 |
22 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$612.75 |