| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
932 |
905 |
$19K |
| D1120 |
Prophylaxis - child |
681 |
664 |
$12K |
| D1110 |
Prophylaxis - adult |
232 |
218 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
37 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
51 |
$3K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$2K |
| D1206 |
Topical application of fluoride varnish |
101 |
101 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$770.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$423.00 |