| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,286 |
1,282 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
814 |
814 |
$18K |
| D1110 |
Prophylaxis - adult |
462 |
462 |
$15K |
| D1120 |
Prophylaxis - child |
510 |
510 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
93 |
$9K |
| D0274 |
Bitewings - four radiographic images |
410 |
410 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
114 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
215 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
29 |
$2K |
| D1351 |
Sealant - per tooth |
51 |
12 |
$1K |
| D1999 |
|
123 |
114 |
$1K |
| D0330 |
Panoramic radiographic image |
113 |
113 |
$309.66 |