| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
763 |
763 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,249 |
1,247 |
$34K |
| D1120 |
Prophylaxis - child |
604 |
602 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
815 |
814 |
$16K |
| D0272 |
Bitewings - two radiographic images |
686 |
683 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
89 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
44 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
88 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$1K |