| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,649 |
2,553 |
$44K |
| D1206 |
Topical application of fluoride varnish |
2,769 |
2,660 |
$41K |
| D1120 |
Prophylaxis - child |
1,595 |
1,534 |
$40K |
| D1110 |
Prophylaxis - adult |
931 |
901 |
$31K |
| D0274 |
Bitewings - four radiographic images |
132 |
126 |
$3K |
| D0272 |
Bitewings - two radiographic images |
132 |
128 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
15 |
$993.72 |
| D1351 |
Sealant - per tooth |
36 |
13 |
$697.07 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$282.48 |
| D1999 |
|
139 |
124 |
$0.00 |