| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
147 |
142 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
108 |
$1K |
| D1110 |
Prophylaxis - adult |
97 |
90 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
82 |
$1K |
| D1206 |
Topical application of fluoride varnish |
159 |
154 |
$883.76 |
| D1120 |
Prophylaxis - child |
70 |
69 |
$494.90 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
14 |
$364.00 |
| D0330 |
Panoramic radiographic image |
48 |
43 |
$236.16 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$93.00 |