| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
818 |
818 |
$31K |
| D1120 |
Prophylaxis - child |
555 |
555 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
566 |
566 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
165 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
245 |
241 |
$4K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$3K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
31 |
$429.50 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$312.00 |