| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,534 |
1,534 |
$65K |
| D1351 |
Sealant - per tooth |
738 |
385 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,655 |
1,655 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
506 |
423 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,556 |
1,556 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,117 |
1,117 |
$20K |
| D1110 |
Prophylaxis - adult |
334 |
334 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
2,119 |
2,115 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
467 |
467 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
228 |
210 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,895 |
1,886 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
303 |
299 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
47 |
$5K |
| D0272 |
Bitewings - two radiographic images |
388 |
388 |
$4K |
| D0270 |
|
54 |
54 |
$297.71 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$233.90 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$145.74 |