| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,178 |
1,128 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
845 |
805 |
$22K |
| D1206 |
Topical application of fluoride varnish |
788 |
770 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
156 |
148 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
43 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
109 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
148 |
$818.53 |
| D0272 |
Bitewings - two radiographic images |
88 |
82 |
$699.00 |
| D0274 |
Bitewings - four radiographic images |
42 |
39 |
$601.54 |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
103 |
$364.66 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$243.00 |
| D1999 |
|
12 |
12 |
$0.00 |