| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
417 |
417 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
693 |
692 |
$17K |
| D1206 |
Topical application of fluoride varnish |
491 |
491 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
149 |
137 |
$7K |
| D1110 |
Prophylaxis - adult |
143 |
143 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
887 |
871 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
31 |
$4K |
| D0274 |
Bitewings - four radiographic images |
303 |
302 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
794 |
783 |
$3K |
| D1351 |
Sealant - per tooth |
132 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
26 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$2K |
| D0272 |
Bitewings - two radiographic images |
107 |
107 |
$1K |
| D0330 |
Panoramic radiographic image |
21 |
21 |
$828.35 |
| D0603 |
|
60 |
60 |
$600.00 |
| D0601 |
|
13 |
13 |
$130.00 |