| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
228 |
227 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
143 |
$5K |
| D1206 |
Topical application of fluoride varnish |
250 |
250 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
144 |
127 |
$4K |
| D0330 |
Panoramic radiographic image |
59 |
53 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
50 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
103 |
$1K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$523.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
47 |
$474.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$262.50 |