| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,724 |
2,720 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
3,379 |
3,375 |
$85K |
| D1206 |
Topical application of fluoride varnish |
2,812 |
2,809 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
407 |
238 |
$46K |
| D1110 |
Prophylaxis - adult |
887 |
886 |
$40K |
| D0274 |
Bitewings - four radiographic images |
649 |
649 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
210 |
139 |
$19K |
| D0272 |
Bitewings - two radiographic images |
620 |
617 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
121 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$776.78 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$504.00 |