| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,181 |
2,181 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,774 |
2,774 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,700 |
2,700 |
$56K |
| D1110 |
Prophylaxis - adult |
654 |
654 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
117 |
$19K |
| D0272 |
Bitewings - two radiographic images |
481 |
481 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
26 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$3K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
12 |
$785.36 |