| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,345 |
1,340 |
$34K |
| D1120 |
Prophylaxis - child |
828 |
825 |
$31K |
| D1110 |
Prophylaxis - adult |
594 |
591 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,049 |
1,047 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
65 |
$13K |
| D0274 |
Bitewings - four radiographic images |
293 |
292 |
$9K |
| D0272 |
Bitewings - two radiographic images |
98 |
98 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$559.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$351.86 |