| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,611 |
1,575 |
$70K |
| D1206 |
Topical application of fluoride varnish |
1,666 |
1,619 |
$56K |
| D1351 |
Sealant - per tooth |
2,135 |
439 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,262 |
1,219 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
639 |
628 |
$21K |
| D1353 |
|
992 |
179 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,917 |
1,452 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
451 |
436 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
612 |
593 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
65 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
71 |
$4K |
| D0999 |
Unspecified diagnostic procedure, by report |
96 |
96 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
73 |
61 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
94 |
94 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$889.70 |
| D1999 |
|
20 |
18 |
$0.00 |