| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
905 |
905 |
$26K |
| D1110 |
Prophylaxis - adult |
416 |
416 |
$22K |
| D0274 |
Bitewings - four radiographic images |
710 |
709 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,176 |
1,176 |
$17K |
| D1120 |
Prophylaxis - child |
449 |
449 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$565.12 |
| D0603 |
|
140 |
140 |
$0.00 |
| D0601 |
|
408 |
408 |
$0.00 |
| D0602 |
|
51 |
51 |
$0.00 |