| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,006 |
2,006 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,105 |
2,104 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,300 |
2,299 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
237 |
121 |
$26K |
| D0274 |
Bitewings - four radiographic images |
736 |
736 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,440 |
1,430 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,106 |
1,074 |
$17K |
| D1110 |
Prophylaxis - adult |
215 |
215 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$4K |
| D0272 |
Bitewings - two radiographic images |
121 |
121 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$382.25 |