| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
331 |
313 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
12 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
478 |
454 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
416 |
298 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
350 |
325 |
$4K |
| D1120 |
Prophylaxis - child |
85 |
84 |
$3K |
| D0274 |
Bitewings - four radiographic images |
41 |
38 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$658.56 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$280.56 |
| D0602 |
|
43 |
43 |
$0.00 |
| D0603 |
|
65 |
65 |
$0.00 |