| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
722 |
701 |
$93K |
| D1110 |
Prophylaxis - adult |
740 |
641 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,911 |
1,685 |
$35K |
| D1120 |
Prophylaxis - child |
1,112 |
993 |
$31K |
| D0274 |
Bitewings - four radiographic images |
788 |
697 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
241 |
146 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
642 |
558 |
$9K |
| D0330 |
Panoramic radiographic image |
102 |
83 |
$5K |
| D1351 |
Sealant - per tooth |
46 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
30 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
99 |
$1K |