| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
932 |
932 |
$35K |
| D1120 |
Prophylaxis - child |
1,023 |
1,022 |
$30K |
| D0274 |
Bitewings - four radiographic images |
669 |
668 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,243 |
1,076 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
50 |
$5K |
| D1206 |
Topical application of fluoride varnish |
248 |
248 |
$3K |
| D0272 |
Bitewings - two radiographic images |
270 |
270 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$2K |
| D9430 |
|
32 |
31 |
$1K |
| D0350 |
|
56 |
54 |
$729.24 |