| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
611 |
611 |
$21K |
| D1206 |
Topical application of fluoride varnish |
709 |
709 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
595 |
595 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
33 |
$8K |
| D0330 |
Panoramic radiographic image |
130 |
130 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$6K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$2K |
| D0274 |
Bitewings - four radiographic images |
130 |
130 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$775.46 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$275.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$35.23 |