| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
834 |
834 |
$24K |
| D1110 |
Prophylaxis - adult |
437 |
435 |
$23K |
| D1120 |
Prophylaxis - child |
536 |
536 |
$21K |
| D1206 |
Topical application of fluoride varnish |
813 |
813 |
$19K |
| D0274 |
Bitewings - four radiographic images |
450 |
450 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
50 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
108 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
73 |
$1K |