| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
280 |
239 |
$19K |
| D1120 |
Prophylaxis - child |
144 |
144 |
$5K |
| D1206 |
Topical application of fluoride varnish |
137 |
137 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
105 |
105 |
$2K |
| D0272 |
Bitewings - two radiographic images |
57 |
57 |
$592.20 |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
142 |
$468.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
109 |
$378.00 |
| D9991 |
|
36 |
36 |
$324.00 |
| D0603 |
|
116 |
116 |
$92.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$0.00 |