| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
412 |
408 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
424 |
418 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
669 |
660 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
592 |
553 |
$6K |
| D0272 |
Bitewings - two radiographic images |
250 |
247 |
$6K |
| D1206 |
Topical application of fluoride varnish |
343 |
340 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
147 |
$3K |
| D1351 |
Sealant - per tooth |
76 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
66 |
$945.21 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$940.68 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$713.44 |
| D0601 |
|
657 |
649 |
$48.12 |
| D0602 |
|
15 |
12 |
$0.00 |