| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,881 |
6,713 |
$271K |
| D1351 |
Sealant - per tooth |
4,130 |
2,480 |
$222K |
| D0120 |
Periodic oral evaluation - established patient |
6,419 |
6,243 |
$176K |
| D1206 |
Topical application of fluoride varnish |
6,909 |
6,739 |
$170K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$678.70 |
| D0274 |
Bitewings - four radiographic images |
23 |
23 |
$388.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$382.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
15 |
$106.40 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
17 |
$84.00 |
| D0601 |
|
1,719 |
1,689 |
$0.00 |
| D0603 |
|
1,132 |
1,123 |
$0.00 |
| D0602 |
|
2,478 |
2,445 |
$0.00 |