| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,033 |
1,033 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,431 |
1,430 |
$41K |
| D1110 |
Prophylaxis - adult |
338 |
338 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
645 |
644 |
$15K |
| D0272 |
Bitewings - two radiographic images |
573 |
572 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
53 |
$10K |
| D0330 |
Panoramic radiographic image |
104 |
104 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$543.96 |