| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,311 |
1,300 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,536 |
1,521 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
878 |
870 |
$18K |
| D0272 |
Bitewings - two radiographic images |
363 |
360 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
209 |
$5K |
| D0603 |
|
407 |
402 |
$4K |
| D1330 |
|
737 |
728 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
117 |
117 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
213 |
210 |
$2K |
| D0602 |
|
150 |
147 |
$1K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
105 |
$913.00 |
| D0601 |
|
31 |
31 |
$300.00 |
| D1310 |
|
368 |
363 |
$7.00 |