| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
768 |
696 |
$40K |
| D1120 |
Prophylaxis - child |
956 |
845 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,397 |
1,257 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,004 |
902 |
$26K |
| D0274 |
Bitewings - four radiographic images |
298 |
273 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
445 |
388 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
30 |
$1K |
| D0272 |
Bitewings - two radiographic images |
52 |
41 |
$1K |
| D0603 |
|
26 |
25 |
$617.94 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$0.00 |