| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
409 |
405 |
$8K |
| D1120 |
Prophylaxis - child |
225 |
224 |
$6K |
| D1110 |
Prophylaxis - adult |
218 |
214 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
22 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
26 |
$1K |
| D0330 |
Panoramic radiographic image |
51 |
49 |
$200.65 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$141.21 |
| D1208 |
Topical application of fluoride, excluding varnish |
133 |
132 |
$72.83 |
| D1330 |
|
467 |
462 |
$0.00 |
| D1999 |
|
73 |
72 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$0.00 |