| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,249 |
1,217 |
$52K |
| D1206 |
Topical application of fluoride varnish |
2,053 |
2,008 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,709 |
1,670 |
$49K |
| D1110 |
Prophylaxis - adult |
321 |
313 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
44 |
$9K |
| D1330 |
|
870 |
841 |
$5K |
| D0274 |
Bitewings - four radiographic images |
176 |
176 |
$4K |
| D1351 |
Sealant - per tooth |
89 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
39 |
$403.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$276.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
30 |
$196.80 |