| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,201 |
2,132 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,771 |
1,743 |
$41K |
| D1120 |
Prophylaxis - child |
952 |
938 |
$26K |
| D1110 |
Prophylaxis - adult |
685 |
672 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
229 |
142 |
$19K |
| D1999 |
|
1,272 |
1,125 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
143 |
94 |
$9K |
| D0272 |
Bitewings - two radiographic images |
285 |
279 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
61 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$584.28 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$256.85 |