| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
145 |
144 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
176 |
175 |
$5K |
| D1206 |
Topical application of fluoride varnish |
184 |
182 |
$3K |
| D1110 |
Prophylaxis - adult |
47 |
46 |
$2K |
| D9248 |
|
33 |
20 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
63 |
$2K |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
77 |
$942.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$281.70 |
| D1330 |
|
36 |
21 |
$232.75 |
| D0603 |
|
202 |
200 |
$0.00 |