| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,808 |
1,785 |
$70K |
| D1110 |
Prophylaxis - adult |
883 |
882 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,223 |
2,187 |
$28K |
| D1351 |
Sealant - per tooth |
1,139 |
224 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
710 |
678 |
$18K |
| D1206 |
Topical application of fluoride varnish |
298 |
298 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
166 |
$875.39 |
| D0273 |
|
77 |
71 |
$852.00 |
| D0603 |
|
69 |
60 |
$570.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$455.00 |
| D0602 |
|
25 |
25 |
$250.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$182.67 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
25 |
$126.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$80.50 |