| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,268 |
1,241 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,946 |
1,864 |
$35K |
| D1120 |
Prophylaxis - child |
622 |
579 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
95 |
$9K |
| D0274 |
Bitewings - four radiographic images |
293 |
290 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
232 |
221 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
52 |
$3K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$394.83 |