| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
192 |
183 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
152 |
148 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
143 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
96 |
$2K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D0274 |
Bitewings - four radiographic images |
104 |
103 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
246 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
208 |
202 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
55 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$738.66 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$312.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$293.80 |
| D9310 |
|
12 |
12 |
$205.20 |
| D0270 |
|
15 |
15 |
$84.00 |