| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,208 |
2,190 |
$68K |
| D1120 |
Prophylaxis - child |
1,563 |
1,554 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,541 |
2,523 |
$40K |
| D1110 |
Prophylaxis - adult |
666 |
660 |
$36K |
| D0272 |
Bitewings - two radiographic images |
154 |
154 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$2K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$260.00 |