| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,373 |
4,370 |
$178K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,727 |
821 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
4,079 |
4,077 |
$112K |
| D0274 |
Bitewings - four radiographic images |
2,076 |
2,076 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,307 |
2,305 |
$66K |
| D1351 |
Sealant - per tooth |
1,111 |
353 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,775 |
2,772 |
$39K |
| D1354 |
|
1,054 |
507 |
$39K |
| D1110 |
Prophylaxis - adult |
590 |
590 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
795 |
795 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
189 |
78 |
$15K |
| D0330 |
Panoramic radiographic image |
100 |
100 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
28 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
253 |
250 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$207.80 |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$0.00 |
| D1999 |
|
16 |
16 |
$0.00 |