| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,258 |
2,257 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,566 |
2,563 |
$63K |
| D1206 |
Topical application of fluoride varnish |
2,577 |
2,573 |
$58K |
| D1110 |
Prophylaxis - adult |
506 |
504 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
55 |
$10K |
| D0272 |
Bitewings - two radiographic images |
449 |
448 |
$10K |
| D0274 |
Bitewings - four radiographic images |
101 |
100 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$559.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$221.00 |