| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
979 |
979 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,472 |
1,472 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,157 |
1,157 |
$36K |
| D1351 |
Sealant - per tooth |
1,647 |
263 |
$33K |
| D1110 |
Prophylaxis - adult |
141 |
141 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
346 |
345 |
$3K |
| D0603 |
|
374 |
369 |
$3K |
| D0251 |
|
101 |
101 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$2K |
| D0274 |
Bitewings - four radiographic images |
192 |
192 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
27 |
$2K |
| D0602 |
|
115 |
115 |
$1K |
| D0250 |
|
56 |
56 |
$560.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$260.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$145.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$104.00 |
| D0601 |
|
12 |
12 |
$90.00 |
| D1330 |
|
584 |
571 |
$0.00 |
| D1310 |
|
584 |
571 |
$0.00 |