| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
673 |
515 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
643 |
485 |
$13K |
| D1206 |
Topical application of fluoride varnish |
419 |
316 |
$8K |
| D0274 |
Bitewings - four radiographic images |
175 |
133 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
17 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
30 |
$884.10 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$492.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$456.85 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
55 |
$296.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
30 |
$292.60 |
| D0270 |
|
14 |
14 |
$78.40 |