| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,603 |
2,603 |
$51K |
| D1120 |
Prophylaxis - child |
1,698 |
1,698 |
$48K |
| D1110 |
Prophylaxis - adult |
1,161 |
1,161 |
$48K |
| D1206 |
Topical application of fluoride varnish |
3,064 |
3,064 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,580 |
1,580 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
2,369 |
2,364 |
$33K |
| D0350 |
|
1,175 |
1,175 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,948 |
2,150 |
$28K |
| D0240 |
|
1,418 |
1,416 |
$24K |
| D0330 |
Panoramic radiographic image |
488 |
488 |
$22K |
| D1351 |
Sealant - per tooth |
640 |
191 |
$14K |
| D1320 |
|
285 |
284 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
37 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$1K |
| D3120 |
|
23 |
14 |
$668.15 |