| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
171 |
166 |
$5K |
| D1120 |
Prophylaxis - child |
111 |
108 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
15 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
144 |
138 |
$2K |
| D0272 |
Bitewings - two radiographic images |
44 |
40 |
$848.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
19 |
$391.34 |
| D0220 |
Intraoral - periapical first radiographic image |
22 |
22 |
$270.62 |
| D0603 |
|
282 |
272 |
$0.00 |