| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,653 |
2,614 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
2,300 |
2,273 |
$65K |
| D1206 |
Topical application of fluoride varnish |
1,280 |
1,255 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
112 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
74 |
$5K |
| D0272 |
Bitewings - two radiographic images |
282 |
280 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
74 |
$2K |
| D0330 |
Panoramic radiographic image |
78 |
78 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$426.24 |