| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
893 |
888 |
$39K |
| D1120 |
Prophylaxis - child |
945 |
940 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
124 |
$17K |
| D1206 |
Topical application of fluoride varnish |
876 |
871 |
$15K |
| D0272 |
Bitewings - two radiographic images |
619 |
615 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,003 |
995 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,120 |
918 |
$12K |
| D0274 |
Bitewings - four radiographic images |
78 |
77 |
$3K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$923.35 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$514.20 |