| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
934 |
890 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
973 |
927 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,111 |
1,054 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
94 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
47 |
41 |
$2K |
| D0272 |
Bitewings - two radiographic images |
69 |
65 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
78 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
25 |
$784.72 |