| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
633 |
632 |
$35K |
| D1120 |
Prophylaxis - child |
559 |
556 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,002 |
722 |
$13K |
| D0350 |
|
1,417 |
683 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
62 |
$9K |
| D1206 |
Topical application of fluoride varnish |
523 |
521 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
602 |
544 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
104 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
26 |
$3K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$168.00 |
| D1999 |
|
23 |
20 |
$0.00 |