| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,135 |
1,095 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,243 |
1,203 |
$32K |
| D0272 |
Bitewings - two radiographic images |
818 |
790 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,204 |
1,163 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
35 |
$6K |
| D1110 |
Prophylaxis - adult |
115 |
113 |
$6K |
| D0274 |
Bitewings - four radiographic images |
151 |
149 |
$5K |
| D1351 |
Sealant - per tooth |
181 |
24 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
102 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
29 |
$914.79 |
| D0603 |
|
1,114 |
1,086 |
$0.00 |
| D1310 |
|
15 |
15 |
$0.00 |
| D0601 |
|
17 |
17 |
$0.00 |
| D0602 |
|
29 |
28 |
$0.00 |