| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
559 |
559 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
518 |
518 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
394 |
394 |
$5K |
| D0272 |
Bitewings - two radiographic images |
247 |
247 |
$3K |
| D1206 |
Topical application of fluoride varnish |
112 |
111 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$627.38 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$329.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
53 |
$265.00 |