| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,402 |
1,397 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
945 |
943 |
$37K |
| D9310 |
|
308 |
308 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
852 |
848 |
$19K |
| D1206 |
Topical application of fluoride varnish |
517 |
517 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
26 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
250 |
248 |
$6K |
| D1351 |
Sealant - per tooth |
127 |
45 |
$3K |
| D0272 |
Bitewings - two radiographic images |
113 |
113 |
$3K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$2K |
| D4355 |
|
14 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
34 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$237.25 |