| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,157 |
1,142 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
340 |
246 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,152 |
1,137 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
293 |
195 |
$14K |
| D0274 |
Bitewings - four radiographic images |
520 |
517 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
103 |
$2K |
| D1206 |
Topical application of fluoride varnish |
148 |
146 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$821.20 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$240.02 |