| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
505 |
504 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
690 |
689 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
595 |
595 |
$14K |
| D1110 |
Prophylaxis - adult |
73 |
73 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$457.10 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$286.00 |