| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,075 |
1,075 |
$57K |
| D1206 |
Topical application of fluoride varnish |
1,113 |
1,112 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
977 |
977 |
$33K |
| D1351 |
Sealant - per tooth |
460 |
93 |
$11K |
| D0272 |
Bitewings - two radiographic images |
506 |
505 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
767 |
767 |
$5K |
| D0603 |
|
787 |
784 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
49 |
$4K |
| D0274 |
Bitewings - four radiographic images |
246 |
246 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
597 |
597 |
$3K |
| D9920 |
|
38 |
38 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
30 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$884.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$874.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$560.00 |