| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
587 |
585 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
837 |
835 |
$23K |
| D1110 |
Prophylaxis - adult |
425 |
425 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
98 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
580 |
578 |
$14K |
| D0274 |
Bitewings - four radiographic images |
231 |
231 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
27 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$2K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$1K |