| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
487 |
460 |
$13K |
| D1206 |
Topical application of fluoride varnish |
481 |
455 |
$6K |
| D1120 |
Prophylaxis - child |
251 |
236 |
$5K |
| D0272 |
Bitewings - two radiographic images |
291 |
276 |
$4K |
| D1110 |
Prophylaxis - adult |
120 |
116 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
31 |
$1K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$897.00 |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$561.00 |