| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,060 |
1,035 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
135 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
758 |
749 |
$35K |
| D1110 |
Prophylaxis - adult |
318 |
316 |
$22K |
| D1120 |
Prophylaxis - child |
351 |
349 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
108 |
108 |
$10K |
| D1999 |
|
990 |
903 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
155 |
$7K |
| D0274 |
Bitewings - four radiographic images |
152 |
149 |
$5K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$858.41 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.20 |