| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
819 |
819 |
$37K |
| D9920 |
|
889 |
734 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
452 |
400 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
531 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
98 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
462 |
462 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
436 |
435 |
$11K |
| D1206 |
Topical application of fluoride varnish |
340 |
340 |
$11K |
| D1110 |
Prophylaxis - adult |
213 |
213 |
$10K |
| D0274 |
Bitewings - four radiographic images |
410 |
410 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
918 |
871 |
$5K |
| D1351 |
Sealant - per tooth |
182 |
24 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
732 |
727 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$1K |
| D0601 |
|
123 |
123 |
$1K |
| D0272 |
Bitewings - two radiographic images |
123 |
123 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$540.00 |