| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
249 |
241 |
$6K |
| D1206 |
Topical application of fluoride varnish |
234 |
230 |
$4K |
| D1120 |
Prophylaxis - child |
147 |
144 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
82 |
$653.10 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$599.64 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$330.66 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$302.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
55 |
$122.25 |