| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
224 |
193 |
$6K |
| D1206 |
Topical application of fluoride varnish |
218 |
187 |
$4K |
| D1110 |
Prophylaxis - adult |
65 |
54 |
$3K |
| D0272 |
Bitewings - two radiographic images |
111 |
89 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
30 |
25 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
25 |
$706.80 |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$689.70 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$74.10 |