| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
434 |
379 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
380 |
347 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
416 |
361 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
45 |
$1K |
| D1206 |
Topical application of fluoride varnish |
47 |
43 |
$594.00 |
| D0272 |
Bitewings - two radiographic images |
32 |
29 |
$535.08 |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$444.60 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$111.80 |