| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,439 |
1,407 |
$31K |
| D1110 |
Prophylaxis - adult |
790 |
790 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
938 |
938 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
339 |
339 |
$15K |
| D1120 |
Prophylaxis - child |
336 |
336 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
371 |
371 |
$8K |
| D0274 |
Bitewings - four radiographic images |
589 |
589 |
$8K |
| D1999 |
|
533 |
488 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
682 |
670 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
25 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
804 |
352 |
$3K |
| D0330 |
Panoramic radiographic image |
305 |
305 |
$3K |
| D1351 |
Sealant - per tooth |
55 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
55 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$104.00 |