| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,497 |
1,494 |
$44K |
| D1110 |
Prophylaxis - adult |
740 |
737 |
$41K |
| D1120 |
Prophylaxis - child |
633 |
632 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
590 |
590 |
$14K |
| D0272 |
Bitewings - two radiographic images |
123 |
123 |
$3K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$322.68 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$183.84 |