| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
927 |
927 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,590 |
1,590 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,792 |
1,792 |
$29K |
| D1120 |
Prophylaxis - child |
745 |
745 |
$26K |
| D0272 |
Bitewings - two radiographic images |
828 |
828 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
157 |
$6K |
| D0330 |
Panoramic radiographic image |
97 |
97 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
26 |
$3K |