| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
668 |
668 |
$25K |
| D1110 |
Prophylaxis - adult |
340 |
340 |
$17K |
| D1206 |
Topical application of fluoride varnish |
550 |
550 |
$14K |
| D0274 |
Bitewings - four radiographic images |
150 |
150 |
$6K |
| D1120 |
Prophylaxis - child |
120 |
120 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
234 |
234 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
15 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
49 |
$796.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$191.20 |