| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
839 |
808 |
$16K |
| D1120 |
Prophylaxis - child |
545 |
524 |
$15K |
| D1206 |
Topical application of fluoride varnish |
801 |
771 |
$13K |
| D1110 |
Prophylaxis - adult |
161 |
152 |
$6K |
| D0274 |
Bitewings - four radiographic images |
66 |
64 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
52 |
$651.30 |
| D0330 |
Panoramic radiographic image |
18 |
14 |
$534.24 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$220.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$137.40 |