| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
178 |
133 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
184 |
138 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
164 |
122 |
$3K |
| D0274 |
Bitewings - four radiographic images |
72 |
59 |
$997.10 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$932.15 |
| D1110 |
Prophylaxis - adult |
17 |
14 |
$330.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
13 |
$273.65 |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
38 |
$207.20 |