| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
798 |
753 |
$24K |
| D1120 |
Prophylaxis - child |
589 |
581 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
142 |
$19K |
| D1206 |
Topical application of fluoride varnish |
439 |
424 |
$13K |
| D1110 |
Prophylaxis - adult |
212 |
197 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
55 |
12 |
$7K |
| D0274 |
Bitewings - four radiographic images |
189 |
177 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
33 |
$3K |
| D1330 |
|
141 |
129 |
$952.50 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$280.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$280.00 |