| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
416 |
410 |
$23K |
| D1206 |
Topical application of fluoride varnish |
466 |
459 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
322 |
321 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
28 |
$918.00 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$900.00 |
| D0603 |
|
95 |
92 |
$660.00 |
| D0601 |
|
67 |
65 |
$500.00 |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
74 |
$455.00 |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$270.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
58 |
$270.00 |
| D0602 |
|
29 |
29 |
$170.00 |