| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,432 |
1,415 |
$44K |
| D1120 |
Prophylaxis - child |
967 |
967 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,490 |
1,490 |
$38K |
| D1110 |
Prophylaxis - adult |
283 |
283 |
$13K |
| D0274 |
Bitewings - four radiographic images |
609 |
609 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,120 |
1,113 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,401 |
1,381 |
$7K |
| D0272 |
Bitewings - two radiographic images |
505 |
505 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
24 |
$4K |
| D0330 |
Panoramic radiographic image |
93 |
93 |
$4K |
| D1351 |
Sealant - per tooth |
136 |
37 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
56 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$1K |
| D0602 |
|
72 |
72 |
$720.00 |
| D0603 |
|
12 |
12 |
$120.00 |