| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,624 |
2,482 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
2,477 |
2,356 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,608 |
2,468 |
$66K |
| D1351 |
Sealant - per tooth |
789 |
412 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
298 |
189 |
$22K |
| D0272 |
Bitewings - two radiographic images |
652 |
601 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
24 |
$2K |
| D2332 |
|
16 |
13 |
$1K |
| D9110 |
|
14 |
14 |
$770.00 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$583.00 |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
55 |
$392.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
24 |
$169.12 |
| D1999 |
|
203 |
167 |
$0.00 |