| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,285 |
1,283 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
358 |
210 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,679 |
1,678 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,479 |
1,478 |
$37K |
| D1110 |
Prophylaxis - adult |
452 |
452 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,007 |
987 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
935 |
780 |
$8K |
| D0274 |
Bitewings - four radiographic images |
158 |
157 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
117 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
36 |
$3K |
| D0272 |
Bitewings - two radiographic images |
113 |
113 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D1999 |
|
229 |
201 |
$0.00 |