| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,273 |
1,253 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,260 |
1,240 |
$43K |
| D1351 |
Sealant - per tooth |
574 |
68 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
78 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
647 |
631 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
301 |
298 |
$8K |
| D0274 |
Bitewings - four radiographic images |
289 |
279 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
202 |
195 |
$6K |
| D1110 |
Prophylaxis - adult |
86 |
86 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
584 |
556 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
32 |
$2K |
| D0601 |
|
229 |
226 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
13 |
13 |
$390.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$260.00 |
| D1999 |
|
28 |
23 |
$0.00 |