| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,802 |
1,672 |
$67K |
| D1206 |
Topical application of fluoride varnish |
3,427 |
3,184 |
$62K |
| D1120 |
Prophylaxis - child |
1,323 |
1,222 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,757 |
1,652 |
$37K |
| D0274 |
Bitewings - four radiographic images |
989 |
926 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
407 |
362 |
$10K |
| D0330 |
Panoramic radiographic image |
274 |
240 |
$8K |
| D0272 |
Bitewings - two radiographic images |
435 |
400 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
55 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$1K |
| D1999 |
|
100 |
54 |
$0.00 |