| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
312 |
311 |
$6K |
| D1110 |
Prophylaxis - adult |
103 |
103 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
86 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
232 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
69 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
207 |
78 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$781.00 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$580.00 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$560.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$520.00 |
| D0603 |
|
342 |
340 |
$2.77 |
| D1310 |
|
680 |
649 |
$0.20 |
| D1330 |
|
768 |
723 |
$0.01 |