| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
805 |
754 |
$10K |
| D1110 |
Prophylaxis - adult |
198 |
185 |
$9K |
| D1120 |
Prophylaxis - child |
294 |
276 |
$9K |
| D1351 |
Sealant - per tooth |
386 |
68 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
225 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
260 |
251 |
$7K |
| D0274 |
Bitewings - four radiographic images |
301 |
275 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
545 |
509 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
542 |
457 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
13 |
$3K |
| D0330 |
Panoramic radiographic image |
151 |
143 |
$3K |
| D0272 |
Bitewings - two radiographic images |
136 |
132 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$2K |
| D0240 |
|
98 |
44 |
$487.06 |
| D1999 |
|
85 |
60 |
$0.00 |
| D0603 |
|
1,072 |
1,021 |
$0.00 |