| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,170 |
1,169 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,214 |
1,211 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,163 |
1,163 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
431 |
431 |
$16K |
| D1110 |
Prophylaxis - adult |
298 |
298 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
823 |
812 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
50 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
739 |
689 |
$5K |
| D0274 |
Bitewings - four radiographic images |
226 |
224 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
79 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
98 |
98 |
$2K |