| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,585 |
1,584 |
$73K |
| D1206 |
Topical application of fluoride varnish |
1,740 |
1,739 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
563 |
334 |
$39K |
| D1351 |
Sealant - per tooth |
1,865 |
422 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,440 |
1,438 |
$38K |
| D0330 |
Panoramic radiographic image |
211 |
211 |
$9K |
| D0272 |
Bitewings - two radiographic images |
522 |
522 |
$5K |
| D0602 |
|
568 |
567 |
$5K |
| D0603 |
|
407 |
407 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$3K |
| D0274 |
Bitewings - four radiographic images |
184 |
184 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0601 |
|
109 |
109 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$540.00 |
| D0350 |
|
76 |
76 |
$380.00 |
| D9920 |
|
15 |
15 |
$375.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$340.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$70.00 |