| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
626 |
615 |
$32K |
| D1120 |
Prophylaxis - child |
365 |
355 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
611 |
564 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
917 |
882 |
$14K |
| D0274 |
Bitewings - four radiographic images |
655 |
602 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,368 |
718 |
$7K |
| D0330 |
Panoramic radiographic image |
216 |
199 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
66 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
128 |
$4K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D9215 |
|
300 |
211 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$797.76 |