| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
849 |
690 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
53 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
325 |
266 |
$7K |
| D0274 |
Bitewings - four radiographic images |
283 |
243 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
143 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
267 |
220 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
107 |
90 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
76 |
$822.84 |
| D0330 |
Panoramic radiographic image |
15 |
13 |
$708.72 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
13 |
$520.43 |