| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
871 |
860 |
$39K |
| D1120 |
Prophylaxis - child |
818 |
808 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
799 |
788 |
$15K |
| D0272 |
Bitewings - two radiographic images |
665 |
657 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
618 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
586 |
575 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
16 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$2K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$871.29 |