| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,230 |
1,227 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
334 |
158 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,099 |
1,096 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,224 |
1,222 |
$24K |
| D0272 |
Bitewings - two radiographic images |
642 |
641 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$892.00 |