| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
283 |
269 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
393 |
369 |
$12K |
| D1206 |
Topical application of fluoride varnish |
318 |
302 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
188 |
184 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
271 |
127 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
185 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
412 |
399 |
$5K |
| D0274 |
Bitewings - four radiographic images |
235 |
231 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
57 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
677 |
312 |
$3K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
97 |
$2K |
| D1351 |
Sealant - per tooth |
67 |
13 |
$1K |
| D0270 |
|
12 |
12 |
$141.48 |