| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
314 |
314 |
$8K |
| D1110 |
Prophylaxis - adult |
88 |
88 |
$4K |
| D1206 |
Topical application of fluoride varnish |
52 |
52 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
217 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$540.24 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$300.13 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
68 |
$222.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$180.00 |