| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
978 |
855 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
601 |
523 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
304 |
255 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
442 |
365 |
$5K |
| D1206 |
Topical application of fluoride varnish |
120 |
106 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
50 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
95 |
$2K |
| D0272 |
Bitewings - two radiographic images |
60 |
49 |
$1K |
| D0330 |
Panoramic radiographic image |
19 |
13 |
$684.19 |
| D0274 |
Bitewings - four radiographic images |
19 |
15 |
$431.40 |