| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,010 |
1,009 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,472 |
1,469 |
$37K |
| D1206 |
Topical application of fluoride varnish |
712 |
711 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
478 |
478 |
$10K |
| D1110 |
Prophylaxis - adult |
196 |
195 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
586 |
582 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
639 |
414 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
52 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$767.25 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$288.00 |