| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
302 |
226 |
$4K |
| D1206 |
Topical application of fluoride varnish |
291 |
219 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
269 |
197 |
$4K |
| D0274 |
Bitewings - four radiographic images |
127 |
93 |
$2K |
| D0330 |
Panoramic radiographic image |
41 |
34 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
41 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$446.58 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
14 |
$346.77 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$147.78 |
| D1330 |
|
89 |
75 |
$0.00 |