| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
245 |
224 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
52 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
183 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
143 |
$5K |
| D0274 |
Bitewings - four radiographic images |
87 |
79 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
105 |
99 |
$3K |
| D1120 |
Prophylaxis - child |
39 |
33 |
$931.50 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$883.96 |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
66 |
$850.82 |
| D0272 |
Bitewings - two radiographic images |
24 |
16 |
$372.15 |
| D1206 |
Topical application of fluoride varnish |
18 |
14 |
$267.00 |