| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
558 |
543 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
731 |
715 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
191 |
84 |
$12K |
| D1206 |
Topical application of fluoride varnish |
609 |
593 |
$9K |
| D1110 |
Prophylaxis - adult |
201 |
196 |
$7K |
| D0272 |
Bitewings - two radiographic images |
245 |
237 |
$4K |
| D0274 |
Bitewings - four radiographic images |
45 |
45 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
87 |
$985.00 |