| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
164 |
$6K |
| D1120 |
Prophylaxis - child |
194 |
143 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
159 |
117 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$861.48 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$830.64 |
| D0272 |
Bitewings - two radiographic images |
18 |
16 |
$299.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$146.00 |