| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
655 |
655 |
$20K |
| D1120 |
Prophylaxis - child |
369 |
369 |
$16K |
| D1110 |
Prophylaxis - adult |
299 |
299 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
497 |
497 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
802 |
785 |
$4K |
| D0274 |
Bitewings - four radiographic images |
264 |
264 |
$3K |
| D0330 |
Panoramic radiographic image |
75 |
75 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
24 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
694 |
693 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$2K |
| D0272 |
Bitewings - two radiographic images |
123 |
123 |
$1K |
| D0602 |
|
28 |
28 |
$280.00 |