| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,418 |
1,258 |
$28K |
| D4910 |
|
217 |
211 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
45 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
235 |
228 |
$5K |
| D9920 |
|
90 |
65 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
43 |
42 |
$2K |
| D4355 |
|
13 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$648.43 |
| D0350 |
|
19 |
19 |
$624.65 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$525.33 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$461.24 |