| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,118 |
1,118 |
$45K |
| D1351 |
Sealant - per tooth |
1,435 |
184 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,331 |
1,331 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,242 |
1,242 |
$33K |
| D1110 |
Prophylaxis - adult |
341 |
341 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
65 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
642 |
638 |
$10K |
| D0274 |
Bitewings - four radiographic images |
288 |
288 |
$9K |
| D0240 |
|
289 |
145 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
546 |
503 |
$5K |
| D0272 |
Bitewings - two radiographic images |
130 |
130 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$687.58 |