| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,662 |
2,658 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,636 |
3,636 |
$97K |
| D1206 |
Topical application of fluoride varnish |
2,984 |
2,982 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
762 |
413 |
$70K |
| D1110 |
Prophylaxis - adult |
1,221 |
1,220 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
416 |
256 |
$52K |
| D0274 |
Bitewings - four radiographic images |
615 |
614 |
$21K |
| D0272 |
Bitewings - two radiographic images |
538 |
538 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
69 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
65 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
17 |
$198.00 |