| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
495 |
491 |
$27K |
| D1110 |
Prophylaxis - adult |
235 |
231 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,459 |
636 |
$6K |
| D1120 |
Prophylaxis - child |
91 |
90 |
$3K |
| D0274 |
Bitewings - four radiographic images |
92 |
92 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
16 |
$198.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$171.00 |
| D1999 |
|
18 |
17 |
$0.00 |