| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,209 |
1,209 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,465 |
1,465 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,423 |
1,423 |
$32K |
| D1110 |
Prophylaxis - adult |
513 |
513 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
156 |
110 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
67 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$4K |
| D0272 |
Bitewings - two radiographic images |
157 |
157 |
$3K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$612.00 |