| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
383 |
336 |
$9K |
| D1120 |
Prophylaxis - child |
312 |
265 |
$8K |
| D0274 |
Bitewings - four radiographic images |
185 |
158 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
26 |
$4K |
| D1110 |
Prophylaxis - adult |
70 |
64 |
$3K |
| D1206 |
Topical application of fluoride varnish |
240 |
207 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
24 |
$829.71 |
| D0272 |
Bitewings - two radiographic images |
36 |
35 |
$654.64 |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
32 |
$393.96 |
| D0601 |
|
298 |
286 |
$0.00 |
| D0602 |
|
53 |
51 |
$0.00 |
| D1999 |
|
51 |
39 |
$0.00 |