| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,061 |
1,061 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
986 |
986 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,067 |
1,067 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
117 |
$29K |
| D0272 |
Bitewings - two radiographic images |
409 |
409 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
130 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
38 |
38 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$715.00 |
| D0240 |
|
31 |
17 |
$638.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
14 |
$378.00 |