| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
494 |
456 |
$10K |
| D1206 |
Topical application of fluoride varnish |
509 |
472 |
$8K |
| D1120 |
Prophylaxis - child |
282 |
264 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
25 |
$5K |
| D0272 |
Bitewings - two radiographic images |
140 |
127 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
211 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
198 |
146 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$316.21 |