| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,094 |
1,093 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,310 |
1,309 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,249 |
1,248 |
$28K |
| D1110 |
Prophylaxis - adult |
478 |
478 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
52 |
$10K |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$5K |
| D0272 |
Bitewings - two radiographic images |
220 |
220 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
64 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$473.00 |