| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
143 |
134 |
$10K |
| D1206 |
Topical application of fluoride varnish |
237 |
229 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
102 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
33 |
$8K |
| D0274 |
Bitewings - four radiographic images |
97 |
94 |
$6K |
| D0330 |
Panoramic radiographic image |
40 |
36 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
85 |
81 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
25 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
30 |
$793.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
13 |
$735.00 |