| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
422 |
420 |
$12K |
| D0330 |
Panoramic radiographic image |
124 |
123 |
$11K |
| D1120 |
Prophylaxis - child |
214 |
213 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
42 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
138 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
227 |
225 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
38 |
$7K |
| D1110 |
Prophylaxis - adult |
96 |
95 |
$7K |
| D0274 |
Bitewings - four radiographic images |
105 |
105 |
$5K |
| D1351 |
Sealant - per tooth |
118 |
41 |
$5K |
| D0272 |
Bitewings - two radiographic images |
129 |
128 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$463.00 |