| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
165 |
165 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
178 |
178 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
149 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
128 |
$3K |
| D0330 |
Panoramic radiographic image |
137 |
137 |
$3K |
| D0274 |
Bitewings - four radiographic images |
127 |
127 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
85 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
154 |
150 |
$998.11 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$965.94 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
17 |
$691.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
60 |
$261.66 |