| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,087 |
1,086 |
$23K |
| D1110 |
Prophylaxis - adult |
532 |
531 |
$20K |
| D1120 |
Prophylaxis - child |
610 |
607 |
$20K |
| D1206 |
Topical application of fluoride varnish |
496 |
495 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
639 |
631 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
43 |
$7K |
| D0274 |
Bitewings - four radiographic images |
220 |
220 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
567 |
553 |
$4K |
| D0272 |
Bitewings - two radiographic images |
88 |
88 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$518.00 |