| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
860 |
860 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,013 |
1,013 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
873 |
873 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
42 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
657 |
652 |
$9K |
| D1110 |
Prophylaxis - adult |
93 |
93 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
533 |
532 |
$4K |
| D0272 |
Bitewings - two radiographic images |
215 |
215 |
$4K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$636.50 |