| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
152 |
150 |
$4K |
| D1120 |
Prophylaxis - child |
115 |
114 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
218 |
$3K |
| D0274 |
Bitewings - four radiographic images |
92 |
91 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
14 |
$3K |
| D1110 |
Prophylaxis - adult |
54 |
53 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
212 |
210 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
209 |
207 |
$2K |
| D0272 |
Bitewings - two radiographic images |
36 |
35 |
$818.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$494.48 |
| D0601 |
|
26 |
26 |
$0.00 |
| D0603 |
|
172 |
169 |
$0.00 |