| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
97 |
87 |
$2K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
112 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
29 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
91 |
84 |
$940.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
92 |
$771.17 |
| D0601 |
|
40 |
30 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
12 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
27 |
18 |
$0.00 |
| D1110 |
Prophylaxis - adult |
16 |
12 |
$0.00 |