| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
277 |
255 |
$8K |
| D1206 |
Topical application of fluoride varnish |
275 |
254 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
228 |
209 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
24 |
$4K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
123 |
77 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
111 |
$2K |