| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
593 |
551 |
$17K |
| D1120 |
Prophylaxis - child |
468 |
441 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
154 |
$12K |
| T1015 |
Clinic visit/encounter, all-inclusive |
144 |
128 |
$9K |
| D1351 |
Sealant - per tooth |
421 |
129 |
$7K |
| D0330 |
Panoramic radiographic image |
130 |
130 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
114 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
526 |
398 |
$5K |
| D1354 |
|
199 |
63 |
$5K |
| D0274 |
Bitewings - four radiographic images |
155 |
155 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
145 |
$3K |
| D0272 |
Bitewings - two radiographic images |
202 |
202 |
$3K |
| D1110 |
Prophylaxis - adult |
70 |
68 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
19 |
18 |
$425.00 |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
34 |
$390.00 |
| D1330 |
|
92 |
84 |
$0.00 |
| D0602 |
|
18 |
18 |
$0.00 |