| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,271 |
1,246 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,279 |
1,251 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,254 |
1,234 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
78 |
$13K |
| D0274 |
Bitewings - four radiographic images |
265 |
258 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$1K |