| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,040 |
1,038 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
992 |
992 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
218 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
574 |
573 |
$15K |
| D1206 |
Topical application of fluoride varnish |
225 |
225 |
$6K |
| D0274 |
Bitewings - four radiographic images |
328 |
328 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
118 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
618 |
613 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
463 |
460 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
15 |
$1K |
| D1351 |
Sealant - per tooth |
17 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$989.35 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$426.25 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$194.40 |
| D1999 |
|
36 |
22 |
$0.00 |