| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
531 |
419 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
467 |
387 |
$6K |
| D1206 |
Topical application of fluoride varnish |
450 |
355 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
254 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
175 |
125 |
$255.00 |
| D1330 |
|
244 |
131 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
14 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$0.00 |