| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
225 |
220 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
387 |
384 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
28 |
$8K |
| D1120 |
Prophylaxis - child |
170 |
169 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
239 |
239 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
90 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
27 |
$435.60 |