| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
768 |
728 |
$29K |
| D1110 |
Prophylaxis - adult |
893 |
859 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,058 |
1,020 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,225 |
670 |
$16K |
| D0330 |
Panoramic radiographic image |
268 |
251 |
$11K |
| D0274 |
Bitewings - four radiographic images |
558 |
522 |
$10K |
| D1120 |
Prophylaxis - child |
450 |
419 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
302 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
90 |
14 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
177 |
170 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
779 |
733 |
$4K |
| D0272 |
Bitewings - two radiographic images |
17 |
13 |
$100.00 |