| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
394 |
393 |
$10K |
| D1120 |
Prophylaxis - child |
200 |
200 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
378 |
374 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
506 |
332 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
352 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
13 |
$4K |
| D0272 |
Bitewings - two radiographic images |
58 |
57 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$658.56 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$415.32 |
| D0603 |
|
134 |
133 |
$0.00 |
| D0601 |
|
58 |
58 |
$0.00 |