| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,176 |
2,092 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,398 |
2,262 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,550 |
2,425 |
$51K |
| D0272 |
Bitewings - two radiographic images |
703 |
681 |
$15K |
| D1351 |
Sealant - per tooth |
279 |
72 |
$12K |
| D1110 |
Prophylaxis - adult |
231 |
223 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$427.75 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$190.48 |