| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
683 |
683 |
$17K |
| D1120 |
Prophylaxis - child |
427 |
427 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
496 |
496 |
$11K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
16 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
16 |
$2K |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$1K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$456.00 |