| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
823 |
823 |
$22K |
| D1110 |
Prophylaxis - adult |
339 |
339 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
49 |
$9K |
| D1120 |
Prophylaxis - child |
163 |
163 |
$6K |
| D0274 |
Bitewings - four radiographic images |
203 |
203 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
384 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
279 |
276 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
109 |
$1K |
| D1351 |
Sealant - per tooth |
13 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
68 |
68 |
$1K |
| D9991 |
|
32 |
30 |
$288.00 |