| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
812 |
812 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,007 |
1,007 |
$24K |
| D1206 |
Topical application of fluoride varnish |
951 |
951 |
$20K |
| D0274 |
Bitewings - four radiographic images |
455 |
455 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
39 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
39 |
$4K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$3K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$730.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$417.88 |