| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
155 |
155 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
45 |
$5K |
| D1206 |
Topical application of fluoride varnish |
168 |
168 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
138 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
18 |
$2K |
| D1351 |
Sealant - per tooth |
81 |
20 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
36 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$945.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$715.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$703.80 |
| D0240 |
|
40 |
40 |
$693.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$644.00 |
| D0601 |
|
54 |
54 |
$540.00 |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$510.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$195.00 |
| D0350 |
|
18 |
18 |
$18.00 |