| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
757 |
749 |
$23K |
| D1206 |
Topical application of fluoride varnish |
752 |
746 |
$19K |
| D1110 |
Prophylaxis - adult |
233 |
228 |
$15K |
| D1120 |
Prophylaxis - child |
276 |
276 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
24 |
$5K |
| D0274 |
Bitewings - four radiographic images |
118 |
112 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
44 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
87 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
99 |
$983.80 |