| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,620 |
1,591 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,125 |
1,107 |
$33K |
| D1120 |
Prophylaxis - child |
700 |
687 |
$31K |
| D1110 |
Prophylaxis - adult |
296 |
290 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
123 |
$7K |
| D0274 |
Bitewings - four radiographic images |
152 |
142 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$2K |
| D1330 |
|
157 |
151 |
$906.00 |
| D0272 |
Bitewings - two radiographic images |
46 |
44 |
$698.07 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
42 |
$508.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$91.84 |