| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
347 |
250 |
$549.50 |
| D0120 |
Periodic oral evaluation - established patient |
630 |
472 |
$508.00 |
| D1206 |
Topical application of fluoride varnish |
768 |
487 |
$381.04 |
| D0274 |
Bitewings - four radiographic images |
479 |
357 |
$304.80 |
| D0220 |
Intraoral - periapical first radiographic image |
1,110 |
912 |
$276.96 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$180.08 |
| D0230 |
Intraoral - periapical each additional radiographic image |
621 |
452 |
$115.40 |
| D0140 |
Limited oral evaluation - problem focused |
312 |
276 |
$101.60 |
| D0272 |
Bitewings - two radiographic images |
60 |
47 |
$96.96 |
| D1110 |
Prophylaxis - adult |
165 |
154 |
$48.49 |
| D0603 |
|
87 |
87 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
30 |
$0.00 |
| D0602 |
|
27 |
25 |
$0.00 |
| D0601 |
|
28 |
28 |
$0.00 |