| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,897 |
2,895 |
$121K |
| D1351 |
Sealant - per tooth |
935 |
596 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
2,512 |
2,510 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,571 |
1,566 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,080 |
1,080 |
$29K |
| D0274 |
Bitewings - four radiographic images |
969 |
967 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,936 |
1,915 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
468 |
468 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,671 |
1,664 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
196 |
$4K |
| D0272 |
Bitewings - two radiographic images |
307 |
307 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
55 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
13 |
$795.48 |