| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
265 |
257 |
$7K |
| D1120 |
Prophylaxis - child |
113 |
109 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
245 |
236 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
78 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$918.32 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$303.94 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$200.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
19 |
$184.16 |
| D0603 |
|
238 |
235 |
$0.00 |
| D0602 |
|
29 |
27 |
$0.00 |
| D0601 |
|
26 |
26 |
$0.00 |