| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,087 |
904 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,118 |
937 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,392 |
1,173 |
$18K |
| D1110 |
Prophylaxis - adult |
319 |
269 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
57 |
$11K |
| D1351 |
Sealant - per tooth |
579 |
116 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
667 |
555 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
155 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
624 |
501 |
$5K |
| D0272 |
Bitewings - two radiographic images |
348 |
299 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$406.25 |