| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
92 |
88 |
$762.16 |
| D0220 |
Intraoral - periapical first radiographic image |
695 |
653 |
$642.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
80 |
$483.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
485 |
457 |
$373.82 |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
62 |
$294.86 |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$238.74 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
12 |
$179.52 |
| D1351 |
Sealant - per tooth |
29 |
12 |
$163.71 |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$161.04 |
| D0140 |
Limited oral evaluation - problem focused |
62 |
57 |
$54.27 |
| D1110 |
Prophylaxis - adult |
27 |
26 |
$39.64 |
| D1206 |
Topical application of fluoride varnish |
77 |
76 |
$15.16 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$0.00 |
| D2950 |
|
22 |
12 |
$0.00 |