| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
331 |
331 |
$6K |
| D1120 |
Prophylaxis - child |
284 |
284 |
$5K |
| D1206 |
Topical application of fluoride varnish |
423 |
423 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
39 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$3K |
| D0272 |
Bitewings - two radiographic images |
223 |
223 |
$2K |
| D1110 |
Prophylaxis - adult |
99 |
99 |
$2K |
| D0274 |
Bitewings - four radiographic images |
93 |
93 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$924.00 |