| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
537 |
537 |
$12K |
| D1120 |
Prophylaxis - child |
316 |
316 |
$10K |
| D1110 |
Prophylaxis - adult |
229 |
229 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
581 |
581 |
$6K |
| D2750 |
|
12 |
12 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
469 |
469 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
52 |
$4K |
| D0272 |
Bitewings - two radiographic images |
337 |
337 |
$4K |
| D2954 |
|
34 |
26 |
$3K |
| D1206 |
Topical application of fluoride varnish |
120 |
120 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
195 |
195 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
129 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$433.97 |