| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
112 |
111 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
175 |
163 |
$3K |
| D1110 |
Prophylaxis - adult |
69 |
67 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
44 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
77 |
$3K |
| D1351 |
Sealant - per tooth |
74 |
17 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
110 |
109 |
$2K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
63 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$820.00 |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
91 |
$742.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
22 |
$284.00 |