| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
507 |
506 |
$22K |
| D0330 |
Panoramic radiographic image |
214 |
214 |
$9K |
| D1351 |
Sealant - per tooth |
535 |
153 |
$8K |
| D1110 |
Prophylaxis - adult |
243 |
243 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
187 |
141 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
508 |
507 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
319 |
$4K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
23 |
18 |
$3K |
| D1206 |
Topical application of fluoride varnish |
970 |
966 |
$3K |
| D0274 |
Bitewings - four radiographic images |
210 |
209 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
32 |
$2K |
| D0272 |
Bitewings - two radiographic images |
526 |
526 |
$809.04 |
| D1330 |
|
978 |
974 |
$721.94 |
| D0220 |
Intraoral - periapical first radiographic image |
1,136 |
1,127 |
$676.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,038 |
1,020 |
$463.84 |