| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
569 |
565 |
$15K |
| D1120 |
Prophylaxis - child |
262 |
262 |
$13K |
| D1206 |
Topical application of fluoride varnish |
358 |
358 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
86 |
$12K |
| D1110 |
Prophylaxis - adult |
203 |
203 |
$10K |
| D0274 |
Bitewings - four radiographic images |
240 |
240 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
421 |
411 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
299 |
296 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$825.00 |