| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
723 |
722 |
$19K |
| D1120 |
Prophylaxis - child |
302 |
302 |
$10K |
| D1110 |
Prophylaxis - adult |
198 |
197 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
39 |
$7K |
| D0272 |
Bitewings - two radiographic images |
295 |
291 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
208 |
207 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
89 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
42 |
$633.42 |