| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,021 |
905 |
$19K |
| D0274 |
Bitewings - four radiographic images |
616 |
534 |
$18K |
| D1110 |
Prophylaxis - adult |
559 |
477 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
538 |
473 |
$12K |
| D1120 |
Prophylaxis - child |
145 |
135 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
101 |
$4K |
| D0330 |
Panoramic radiographic image |
63 |
46 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
26 |
$812.16 |