| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
393 |
387 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
256 |
252 |
$8K |
| D1120 |
Prophylaxis - child |
176 |
173 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
46 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$1K |
| D0272 |
Bitewings - two radiographic images |
74 |
72 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$809.78 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$780.00 |