| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,175 |
1,174 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,635 |
1,634 |
$43K |
| D1110 |
Prophylaxis - adult |
705 |
705 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,366 |
1,365 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
179 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
37 |
$6K |
| D0272 |
Bitewings - two radiographic images |
248 |
248 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
36 |
$5K |
| D0274 |
Bitewings - four radiographic images |
86 |
86 |
$3K |
| D1351 |
Sealant - per tooth |
78 |
39 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$892.00 |