| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,251 |
1,251 |
$33K |
| D1110 |
Prophylaxis - adult |
540 |
540 |
$27K |
| D1120 |
Prophylaxis - child |
639 |
639 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
719 |
719 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
41 |
$8K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$1K |