| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
675 |
675 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
780 |
779 |
$19K |
| D1206 |
Topical application of fluoride varnish |
825 |
825 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
483 |
470 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
39 |
$5K |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
370 |
336 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$482.62 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$274.45 |