| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
361 |
359 |
$9K |
| D1120 |
Prophylaxis - child |
168 |
168 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
226 |
$3K |
| D1110 |
Prophylaxis - adult |
68 |
68 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
15 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
122 |
122 |
$3K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$2K |
| D1206 |
Topical application of fluoride varnish |
71 |
71 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
142 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$300.00 |