| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,123 |
1,123 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,537 |
1,537 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,314 |
1,313 |
$31K |
| D1110 |
Prophylaxis - adult |
399 |
399 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
78 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
48 |
$5K |
| D0272 |
Bitewings - two radiographic images |
176 |
176 |
$4K |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$430.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$335.10 |