| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
455 |
454 |
$13K |
| D1120 |
Prophylaxis - child |
232 |
230 |
$8K |
| D0272 |
Bitewings - two radiographic images |
161 |
161 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
210 |
210 |
$3K |
| D1206 |
Topical application of fluoride varnish |
208 |
207 |
$3K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$415.32 |
| D0601 |
|
107 |
101 |
$0.00 |
| D0602 |
|
282 |
281 |
$0.00 |