| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
235 |
235 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
320 |
320 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
284 |
284 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
24 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
168 |
$3K |
| D1110 |
Prophylaxis - adult |
55 |
54 |
$3K |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
108 |
102 |
$964.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$436.00 |