| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
573 |
573 |
$15K |
| D1120 |
Prophylaxis - child |
612 |
612 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
82 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
591 |
591 |
$7K |
| D0272 |
Bitewings - two radiographic images |
222 |
222 |
$2K |
| D0240 |
|
50 |
49 |
$729.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$518.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$322.00 |
| D0603 |
|
27 |
27 |
$270.00 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$246.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$78.00 |