| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
798 |
789 |
$20K |
| D1120 |
Prophylaxis - child |
351 |
341 |
$13K |
| D9999 |
Unspecified adjunctive procedure, by report |
102 |
102 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
183 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
325 |
316 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,079 |
1,038 |
$7K |
| D1110 |
Prophylaxis - adult |
74 |
74 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
41 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,094 |
957 |
$2K |
| D9430 |
|
94 |
86 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
24 |
$2K |
| D0274 |
Bitewings - four radiographic images |
90 |
89 |
$709.20 |
| D0272 |
Bitewings - two radiographic images |
87 |
82 |
$557.00 |
| D0350 |
|
22 |
12 |
$146.40 |
| D1330 |
|
778 |
753 |
$0.00 |