| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,769 |
1,768 |
$69K |
| D1206 |
Topical application of fluoride varnish |
1,865 |
1,864 |
$45K |
| D0191 |
|
1,345 |
1,345 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
463 |
463 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
108 |
108 |
$9K |
| D1351 |
Sealant - per tooth |
195 |
58 |
$6K |
| D1110 |
Prophylaxis - adult |
84 |
84 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
24 |
$4K |
| D1354 |
|
64 |
27 |
$2K |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$396.00 |