| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
188 |
176 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
251 |
$7K |
| D1206 |
Topical application of fluoride varnish |
184 |
172 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$874.44 |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
136 |
$843.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
128 |
116 |
$495.84 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$404.42 |
| D0272 |
Bitewings - two radiographic images |
41 |
36 |
$368.82 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$275.34 |
| D0274 |
Bitewings - four radiographic images |
16 |
14 |
$254.84 |