| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
685 |
677 |
$17K |
| D1120 |
Prophylaxis - child |
371 |
369 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
490 |
484 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
12 |
$5K |
| D1110 |
Prophylaxis - adult |
70 |
69 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$3K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$880.00 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$480.00 |