| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
117 |
117 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$6K |
| D1120 |
Prophylaxis - child |
144 |
144 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,269 |
279 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
191 |
191 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
104 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$75.00 |