| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
516 |
496 |
$38K |
| D1120 |
Prophylaxis - child |
272 |
272 |
$770.69 |
| D0120 |
Periodic oral evaluation - established patient |
216 |
216 |
$504.61 |
| D1206 |
Topical application of fluoride varnish |
153 |
153 |
$232.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$87.00 |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
205 |
$84.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$82.50 |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$80.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
153 |
$0.00 |