| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,476 |
1,393 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
857 |
856 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
268 |
268 |
$12K |
| D1120 |
Prophylaxis - child |
404 |
404 |
$10K |
| D1110 |
Prophylaxis - adult |
283 |
283 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
117 |
$2K |
| D1999 |
|
203 |
172 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$665.76 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$182.00 |