| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,111 |
1,085 |
$58K |
| D1206 |
Topical application of fluoride varnish |
1,697 |
1,652 |
$45K |
| D1351 |
Sealant - per tooth |
1,066 |
217 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
724 |
708 |
$42K |
| D0274 |
Bitewings - four radiographic images |
958 |
934 |
$41K |
| D1110 |
Prophylaxis - adult |
510 |
496 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
920 |
895 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
237 |
129 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
679 |
656 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
653 |
426 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
40 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$1K |