| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
411 |
410 |
$9K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
236 |
236 |
$3K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
268 |
267 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
21 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
76 |
$985.72 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$745.70 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$407.04 |