| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
369 |
365 |
$9K |
| D1110 |
Prophylaxis - adult |
104 |
103 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
217 |
215 |
$4K |
| D1120 |
Prophylaxis - child |
108 |
108 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
21 |
$3K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
16 |
$288.80 |