| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
488 |
480 |
$16K |
| D1206 |
Topical application of fluoride varnish |
493 |
485 |
$13K |
| D1120 |
Prophylaxis - child |
240 |
234 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
39 |
$8K |
| D0274 |
Bitewings - four radiographic images |
166 |
162 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
32 |
30 |
$1K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$1K |