| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
563 |
484 |
$32K |
| D1120 |
Prophylaxis - child |
509 |
375 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
151 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
126 |
$12K |
| D0274 |
Bitewings - four radiographic images |
353 |
196 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
425 |
274 |
$100.54 |
| D0603 |
|
328 |
243 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
335 |
250 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
135 |
135 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
87 |
87 |
$0.00 |