| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
622 |
622 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
681 |
681 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
566 |
566 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
39 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
214 |
$9K |
| D1110 |
Prophylaxis - adult |
106 |
106 |
$6K |
| D0274 |
Bitewings - four radiographic images |
215 |
215 |
$6K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
14 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$2K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$528.00 |