| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,136 |
2,085 |
$76K |
| D1110 |
Prophylaxis - adult |
1,162 |
1,119 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
1,954 |
1,929 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
398 |
335 |
$43K |
| D1120 |
Prophylaxis - child |
883 |
877 |
$39K |
| D0274 |
Bitewings - four radiographic images |
784 |
751 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
334 |
242 |
$26K |
| D1351 |
Sealant - per tooth |
688 |
173 |
$23K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$6K |
| D0272 |
Bitewings - two radiographic images |
234 |
234 |
$6K |
| T1015 |
Clinic visit/encounter, all-inclusive |
27 |
27 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
27 |
$810.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$360.00 |