| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,425 |
4,425 |
$190K |
| D0120 |
Periodic oral evaluation - established patient |
5,427 |
5,427 |
$135K |
| D1351 |
Sealant - per tooth |
2,213 |
576 |
$76K |
| D1110 |
Prophylaxis - adult |
1,508 |
1,508 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,480 |
4,480 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
888 |
476 |
$56K |
| D0272 |
Bitewings - two radiographic images |
3,506 |
3,505 |
$46K |
| D0330 |
Panoramic radiographic image |
1,169 |
1,169 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,037 |
1,037 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,747 |
1,747 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
430 |
430 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
260 |
132 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
784 |
784 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
12 |
$3K |
| D0603 |
|
847 |
847 |
$847.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$624.00 |
| D0602 |
|
30 |
30 |
$30.00 |
| D1999 |
|
5,051 |
5,051 |
$0.00 |
| D0251 |
|
13 |
13 |
$0.00 |
| D1310 |
|
1,539 |
1,539 |
$0.00 |
| D1330 |
|
4,861 |
4,861 |
$0.00 |