| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,314 |
1,313 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,127 |
1,127 |
$24K |
| D1120 |
Prophylaxis - child |
674 |
674 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,345 |
1,343 |
$19K |
| D1110 |
Prophylaxis - adult |
297 |
297 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,226 |
1,212 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,232 |
1,164 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
18 |
$3K |
| D0601 |
|
1,678 |
1,677 |
$0.00 |