| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
925 |
878 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
577 |
553 |
$24K |
| D1206 |
Topical application of fluoride varnish |
789 |
741 |
$19K |
| D1351 |
Sealant - per tooth |
455 |
64 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
75 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
119 |
114 |
$9K |
| D0350 |
|
227 |
216 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
179 |
172 |
$5K |
| D0274 |
Bitewings - four radiographic images |
155 |
149 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
29 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
81 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
50 |
$625.54 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
31 |
$580.78 |
| D0272 |
Bitewings - two radiographic images |
16 |
14 |
$299.07 |
| D1999 |
|
31 |
30 |
$0.00 |
| D1330 |
|
206 |
206 |
$0.00 |