| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
904 |
849 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
50 |
$14K |
| D1120 |
Prophylaxis - child |
403 |
374 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
586 |
552 |
$9K |
| D1110 |
Prophylaxis - adult |
140 |
131 |
$5K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$519.26 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
15 |
$259.74 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$193.50 |