| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
487 |
486 |
$18K |
| D1120 |
Prophylaxis - child |
387 |
386 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
375 |
374 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
313 |
$3K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$2K |
| D0272 |
Bitewings - two radiographic images |
145 |
144 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
40 |
$454.00 |