| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,304 |
2,304 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,505 |
2,505 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,453 |
1,453 |
$39K |
| D1354 |
|
1,203 |
295 |
$32K |
| D1110 |
Prophylaxis - adult |
445 |
445 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,282 |
1,282 |
$17K |
| D0272 |
Bitewings - two radiographic images |
787 |
787 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
105 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
231 |
231 |
$6K |
| D1351 |
Sealant - per tooth |
147 |
51 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
36 |
$3K |
| D0601 |
|
226 |
226 |
$225.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$110.22 |
| D0240 |
|
17 |
12 |
$90.00 |
| D0602 |
|
82 |
82 |
$79.00 |