| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,807 |
1,807 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,254 |
2,252 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,700 |
1,699 |
$42K |
| D1110 |
Prophylaxis - adult |
678 |
676 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
262 |
172 |
$32K |
| D0272 |
Bitewings - two radiographic images |
705 |
705 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
168 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
39 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
117 |
$3K |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$2K |