| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,219 |
1,200 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
985 |
905 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
983 |
966 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
145 |
$28K |
| D1120 |
Prophylaxis - child |
1,007 |
996 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,126 |
1,111 |
$11K |
| D0274 |
Bitewings - four radiographic images |
352 |
343 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
200 |
$7K |
| D0330 |
Panoramic radiographic image |
70 |
69 |
$4K |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$2K |
| D0272 |
Bitewings - two radiographic images |
133 |
133 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$965.64 |