| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,000 |
1,934 |
$59K |
| D1110 |
Prophylaxis - adult |
1,108 |
1,061 |
$56K |
| D1120 |
Prophylaxis - child |
1,111 |
1,077 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,540 |
1,492 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,011 |
969 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
84 |
$17K |
| D1206 |
Topical application of fluoride varnish |
75 |
75 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
29 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$678.86 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$620.82 |