| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
751 |
751 |
$34K |
| D1206 |
Topical application of fluoride varnish |
795 |
795 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
587 |
587 |
$16K |
| D0272 |
Bitewings - two radiographic images |
534 |
534 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
796 |
793 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
273 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
757 |
754 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
33 |
$5K |
| D0274 |
Bitewings - four radiographic images |
116 |
116 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
24 |
$3K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$715.20 |