| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,643 |
1,548 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,193 |
2,047 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,857 |
1,752 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
70 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
38 |
$6K |
| D0274 |
Bitewings - four radiographic images |
126 |
124 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
29 |
$2K |
| D1110 |
Prophylaxis - adult |
56 |
50 |
$2K |