| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,126 |
1,126 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,716 |
1,716 |
$26K |
| D1110 |
Prophylaxis - adult |
587 |
587 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,109 |
1,109 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
93 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,273 |
1,269 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
405 |
405 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
190 |
79 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,224 |
1,214 |
$12K |
| D0274 |
Bitewings - four radiographic images |
469 |
469 |
$11K |
| D0272 |
Bitewings - two radiographic images |
408 |
408 |
$7K |
| D1351 |
Sealant - per tooth |
159 |
47 |
$4K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$601.08 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$264.00 |