| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
531 |
236 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
165 |
143 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
257 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
104 |
100 |
$1K |
| D1120 |
Prophylaxis - child |
32 |
26 |
$867.37 |
| D0274 |
Bitewings - four radiographic images |
39 |
30 |
$854.88 |
| D1110 |
Prophylaxis - adult |
21 |
15 |
$604.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
36 |
26 |
$323.40 |
| D0603 |
|
288 |
278 |
$0.00 |
| D0602 |
|
22 |
18 |
$0.00 |