| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,105 |
1,105 |
$28K |
| D1120 |
Prophylaxis - child |
711 |
711 |
$25K |
| D1206 |
Topical application of fluoride varnish |
596 |
596 |
$14K |
| D1110 |
Prophylaxis - adult |
112 |
112 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
226 |
226 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
25 |
$5K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$432.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$275.00 |