| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
464 |
415 |
$11K |
| D0274 |
Bitewings - four radiographic images |
199 |
178 |
$6K |
| D1120 |
Prophylaxis - child |
182 |
158 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
392 |
363 |
$5K |
| D1110 |
Prophylaxis - adult |
113 |
99 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
35 |
24 |
$352.80 |
| D0272 |
Bitewings - two radiographic images |
16 |
12 |
$233.80 |
| D0602 |
|
270 |
260 |
$0.00 |
| D1330 |
|
16 |
15 |
$0.00 |
| D0603 |
|
27 |
24 |
$0.00 |