| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,988 |
2,887 |
$103K |
| D1120 |
Prophylaxis - child |
1,630 |
1,568 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,187 |
2,131 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,740 |
1,681 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
455 |
356 |
$25K |
| D1351 |
Sealant - per tooth |
1,038 |
299 |
$21K |
| D1110 |
Prophylaxis - adult |
484 |
476 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
365 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
89 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
481 |
440 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
42 |
42 |
$1K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$540.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$325.00 |