| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,406 |
2,404 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
730 |
356 |
$84K |
| D1206 |
Topical application of fluoride varnish |
2,343 |
2,341 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,079 |
2,077 |
$55K |
| D1110 |
Prophylaxis - adult |
847 |
847 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,021 |
1,020 |
$23K |
| D0274 |
Bitewings - four radiographic images |
452 |
451 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
325 |
325 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
69 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$379.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$365.00 |