| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
450 |
449 |
$15K |
| D1206 |
Topical application of fluoride varnish |
679 |
679 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
565 |
564 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
14 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
33 |
$1K |
| D9630 |
|
13 |
13 |
$258.31 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$145.34 |