| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,118 |
1,118 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,149 |
1,149 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,080 |
1,078 |
$28K |
| D1351 |
Sealant - per tooth |
243 |
125 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
103 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,144 |
1,139 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,103 |
1,087 |
$8K |
| D0274 |
Bitewings - four radiographic images |
350 |
349 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
98 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
112 |
112 |
$2K |
| D4355 |
|
17 |
17 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
25 |
$897.29 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$461.76 |