| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
286 |
281 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
345 |
338 |
$17K |
| D0272 |
Bitewings - two radiographic images |
766 |
761 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
113 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,426 |
776 |
$5K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$320.00 |