| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
854 |
854 |
$15K |
| D1110 |
Prophylaxis - adult |
324 |
324 |
$12K |
| D0272 |
Bitewings - two radiographic images |
713 |
713 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
696 |
688 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
600 |
598 |
$2K |
| D2332 |
|
31 |
25 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$334.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$272.90 |