| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
113 |
113 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
18 |
$840.00 |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$820.00 |
| D1120 |
Prophylaxis - child |
37 |
37 |
$740.00 |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$540.00 |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
101 |
$400.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
70 |
$378.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$144.00 |