| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,090 |
1,089 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,271 |
1,265 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,376 |
1,368 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
40 |
$6K |
| D1110 |
Prophylaxis - adult |
127 |
126 |
$5K |
| D0272 |
Bitewings - two radiographic images |
213 |
213 |
$5K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$927.00 |