| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,186 |
1,062 |
$41K |
| D1120 |
Prophylaxis - child |
918 |
809 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
436 |
406 |
$9K |
| D0274 |
Bitewings - four radiographic images |
223 |
214 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
109 |
$4K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
49 |
14 |
$980.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$770.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
13 |
$357.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$216.00 |