| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
944 |
935 |
$65K |
| D0274 |
Bitewings - four radiographic images |
237 |
237 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
213 |
132 |
$12K |
| D0272 |
Bitewings - two radiographic images |
410 |
406 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$7K |
| D1120 |
Prophylaxis - child |
903 |
899 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$6K |
| D1206 |
Topical application of fluoride varnish |
850 |
846 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$792.90 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$210.01 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
123 |
80 |
$0.00 |
| D2140 |
|
21 |
12 |
$0.00 |