| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
632 |
632 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
585 |
585 |
$17K |
| D1206 |
Topical application of fluoride varnish |
469 |
469 |
$12K |
| D1351 |
Sealant - per tooth |
77 |
58 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
78 |
$8K |
| D0274 |
Bitewings - four radiographic images |
218 |
218 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
513 |
508 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
116 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
39 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
448 |
447 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$928.20 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$740.62 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$267.68 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$133.08 |