| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
386 |
385 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
642 |
638 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
551 |
545 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
396 |
395 |
$4K |
| D0272 |
Bitewings - two radiographic images |
287 |
286 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
477 |
448 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
24 |
$3K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$486.30 |