| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,690 |
12,684 |
$376K |
| D1206 |
Topical application of fluoride varnish |
20,023 |
20,000 |
$367K |
| D1351 |
Sealant - per tooth |
10,353 |
3,610 |
$276K |
| D0120 |
Periodic oral evaluation - established patient |
3,422 |
3,408 |
$67K |
| D1110 |
Prophylaxis - adult |
1,552 |
1,552 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,684 |
2,684 |
$55K |
| D0272 |
Bitewings - two radiographic images |
1,037 |
1,037 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
502 |
$15K |
| D0274 |
Bitewings - four radiographic images |
220 |
220 |
$6K |
| D1354 |
|
226 |
91 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
25 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
100 |
$905.58 |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$564.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
37 |
$413.66 |