| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,117 |
2,117 |
$81K |
| D1206 |
Topical application of fluoride varnish |
2,356 |
2,355 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,001 |
2,001 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
1,266 |
1,258 |
$20K |
| D1110 |
Prophylaxis - adult |
340 |
340 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,227 |
1,061 |
$10K |
| D0272 |
Bitewings - two radiographic images |
353 |
353 |
$8K |
| D0274 |
Bitewings - four radiographic images |
216 |
216 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
25 |
$5K |
| D0240 |
|
229 |
115 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$2K |