| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,386 |
1,343 |
$57K |
| D1206 |
Topical application of fluoride varnish |
1,220 |
1,189 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,134 |
1,095 |
$31K |
| D0274 |
Bitewings - four radiographic images |
219 |
216 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$982.98 |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
136 |
$867.78 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$615.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
105 |
$453.95 |