| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,321 |
1,320 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
2,259 |
2,257 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,972 |
1,971 |
$40K |
| D1110 |
Prophylaxis - adult |
739 |
739 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
294 |
134 |
$27K |
| D0274 |
Bitewings - four radiographic images |
460 |
460 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
183 |
$5K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$665.28 |
| D9630 |
|
15 |
13 |
$298.05 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$0.00 |