| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,056 |
2,055 |
$43K |
| D1110 |
Prophylaxis - adult |
1,076 |
1,075 |
$41K |
| D1120 |
Prophylaxis - child |
986 |
986 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,097 |
1,097 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,291 |
1,275 |
$16K |
| D0274 |
Bitewings - four radiographic images |
421 |
421 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,117 |
1,105 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
38 |
$4K |
| D0272 |
Bitewings - two radiographic images |
84 |
84 |
$1K |