| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,978 |
1,975 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,345 |
2,341 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,790 |
1,787 |
$40K |
| D1110 |
Prophylaxis - adult |
354 |
354 |
$15K |
| D0274 |
Bitewings - four radiographic images |
295 |
295 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
39 |
$8K |
| D0272 |
Bitewings - two radiographic images |
289 |
288 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
240 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
70 |
$551.30 |