| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
637 |
558 |
$24K |
| D1206 |
Topical application of fluoride varnish |
647 |
568 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
303 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
328 |
303 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
42 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
512 |
264 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
155 |
142 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
74 |
$2K |
| D0274 |
Bitewings - four radiographic images |
78 |
69 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
46 |
$1K |
| D0603 |
|
344 |
300 |
$1K |
| D1351 |
Sealant - per tooth |
53 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$645.75 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$216.00 |
| D0270 |
|
16 |
16 |
$176.85 |
| D0190 |
|
14 |
12 |
$172.08 |