| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,298 |
2,285 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
1,664 |
1,655 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,350 |
1,343 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
881 |
877 |
$25K |
| D0272 |
Bitewings - two radiographic images |
196 |
194 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$4K |
| D1351 |
Sealant - per tooth |
53 |
15 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$847.00 |