| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
244 |
244 |
$6K |
| D1120 |
Prophylaxis - child |
111 |
111 |
$5K |
| D1206 |
Topical application of fluoride varnish |
102 |
102 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
256 |
238 |
$1K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
157 |
151 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$648.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$630.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$350.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$325.00 |