| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
254 |
254 |
$7K |
| D1120 |
Prophylaxis - child |
149 |
149 |
$5K |
| D1206 |
Topical application of fluoride varnish |
252 |
252 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
254 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
265 |
242 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
13 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$969.08 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$768.32 |
| D0350 |
|
107 |
107 |
$0.00 |
| D0601 |
|
323 |
323 |
$0.00 |