| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
512 |
427 |
$18K |
| D1120 |
Prophylaxis - child |
420 |
348 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
63 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
355 |
308 |
$7K |
| D1310 |
|
267 |
184 |
$6K |
| D1330 |
|
270 |
185 |
$5K |
| D0274 |
Bitewings - four radiographic images |
119 |
104 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
59 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$935.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$650.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$520.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$360.10 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$336.00 |