| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,662 |
1,662 |
$82K |
| D1120 |
Prophylaxis - child |
1,283 |
1,283 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,288 |
1,288 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,837 |
1,837 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,520 |
1,707 |
$20K |
| D1110 |
Prophylaxis - adult |
232 |
231 |
$18K |
| D2330 |
|
102 |
63 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$655.20 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$520.00 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$326.00 |