| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,800 |
1,799 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,203 |
2,202 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
440 |
263 |
$53K |
| D1206 |
Topical application of fluoride varnish |
2,163 |
2,161 |
$48K |
| D1110 |
Prophylaxis - adult |
435 |
435 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
64 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
363 |
360 |
$6K |
| D0274 |
Bitewings - four radiographic images |
162 |
162 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
268 |
154 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D0272 |
Bitewings - two radiographic images |
94 |
94 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$979.78 |