| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
639 |
639 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
843 |
842 |
$24K |
| D1110 |
Prophylaxis - adult |
227 |
227 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
127 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
197 |
164 |
$10K |
| D1206 |
Topical application of fluoride varnish |
377 |
377 |
$10K |
| D0274 |
Bitewings - four radiographic images |
516 |
515 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
333 |
333 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,157 |
1,136 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
311 |
299 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
945 |
943 |
$4K |
| D1351 |
Sealant - per tooth |
36 |
24 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
101 |
101 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
111 |
111 |
$3K |
| D0270 |
|
119 |
119 |
$666.40 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$133.08 |