| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
884 |
673 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
554 |
420 |
$15K |
| D1110 |
Prophylaxis - adult |
225 |
166 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
15 |
$5K |
| D1120 |
Prophylaxis - child |
172 |
114 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
331 |
225 |
$4K |
| D0274 |
Bitewings - four radiographic images |
155 |
95 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
310 |
208 |
$3K |
| D0330 |
Panoramic radiographic image |
22 |
14 |
$807.03 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
14 |
$287.92 |
| D1999 |
|
390 |
216 |
$0.00 |
| D0603 |
|
91 |
78 |
$0.00 |
| D0602 |
|
197 |
145 |
$0.00 |