| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
460 |
458 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
623 |
618 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
56 |
$14K |
| D1206 |
Topical application of fluoride varnish |
545 |
541 |
$13K |
| D1110 |
Prophylaxis - adult |
192 |
192 |
$9K |
| D0274 |
Bitewings - four radiographic images |
68 |
67 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
91 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
51 |
$377.50 |