| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
489 |
488 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
78 |
$11K |
| D0274 |
Bitewings - four radiographic images |
347 |
347 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
463 |
463 |
$6K |
| D1110 |
Prophylaxis - adult |
129 |
129 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
472 |
472 |
$5K |
| D1120 |
Prophylaxis - child |
108 |
107 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
193 |
193 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
15 |
$915.10 |