| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
571 |
571 |
$16K |
| D1120 |
Prophylaxis - child |
380 |
380 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
508 |
508 |
$12K |
| D1110 |
Prophylaxis - adult |
218 |
218 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
49 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
382 |
379 |
$6K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
369 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$375.00 |