| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
589 |
573 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,053 |
1,026 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
435 |
432 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
79 |
$9K |
| D1120 |
Prophylaxis - child |
271 |
267 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
255 |
$7K |
| D0274 |
Bitewings - four radiographic images |
261 |
256 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
38 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$690.08 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$561.30 |