| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,163 |
1,162 |
$28K |
| D1120 |
Prophylaxis - child |
658 |
658 |
$23K |
| D1206 |
Topical application of fluoride varnish |
837 |
837 |
$18K |
| D1110 |
Prophylaxis - adult |
317 |
317 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
484 |
481 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
366 |
302 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$852.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$291.73 |