| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,679 |
1,672 |
$40K |
| D1110 |
Prophylaxis - adult |
779 |
779 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,859 |
1,859 |
$31K |
| D1120 |
Prophylaxis - child |
985 |
985 |
$27K |
| D0274 |
Bitewings - four radiographic images |
619 |
619 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
398 |
398 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$639.34 |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
78 |
$614.67 |