| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
925 |
887 |
$23K |
| D1120 |
Prophylaxis - child |
659 |
622 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
908 |
858 |
$16K |
| D1110 |
Prophylaxis - adult |
155 |
148 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
206 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
26 |
$5K |
| D0274 |
Bitewings - four radiographic images |
102 |
98 |
$3K |
| D1206 |
Topical application of fluoride varnish |
55 |
54 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$613.35 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$447.22 |