| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
520 |
518 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
417 |
417 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
327 |
327 |
$7K |
| D1206 |
Topical application of fluoride varnish |
179 |
179 |
$5K |
| D2394 |
|
27 |
24 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
108 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
42 |
$3K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$821.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$201.30 |