| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
461 |
415 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
410 |
372 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
458 |
412 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
16 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
79 |
63 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
27 |
$2K |
| D0330 |
Panoramic radiographic image |
19 |
18 |
$1K |
| D0274 |
Bitewings - four radiographic images |
23 |
22 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
20 |
$372.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
15 |
$316.54 |