| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
418 |
379 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
372 |
341 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
313 |
278 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
53 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
36 |
$3K |
| D0274 |
Bitewings - four radiographic images |
115 |
111 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$273.65 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$72.80 |