| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,721 |
1,704 |
$33K |
| D1351 |
Sealant - per tooth |
1,618 |
516 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,201 |
1,195 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
654 |
643 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,788 |
1,771 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,024 |
1,011 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
790 |
601 |
$8K |
| D0274 |
Bitewings - four radiographic images |
361 |
360 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
644 |
631 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
43 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
28 |
$2K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$599.00 |