| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
895 |
895 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,052 |
1,052 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
55 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
612 |
612 |
$7K |
| D0272 |
Bitewings - two radiographic images |
353 |
353 |
$5K |
| D1206 |
Topical application of fluoride varnish |
223 |
223 |
$5K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$403.20 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$129.36 |