| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,018 |
1,017 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,016 |
1,015 |
$29K |
| D1206 |
Topical application of fluoride varnish |
366 |
364 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
625 |
625 |
$9K |
| D0272 |
Bitewings - two radiographic images |
254 |
254 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$726.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$445.50 |