| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,446 |
1,424 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,372 |
1,343 |
$22K |
| D1351 |
Sealant - per tooth |
945 |
279 |
$20K |
| D1120 |
Prophylaxis - child |
888 |
866 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
233 |
112 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
44 |
$4K |
| D1110 |
Prophylaxis - adult |
79 |
79 |
$3K |
| D1999 |
|
262 |
238 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
52 |
$2K |
| D0272 |
Bitewings - two radiographic images |
97 |
97 |
$987.84 |
| D0274 |
Bitewings - four radiographic images |
44 |
43 |
$646.29 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$330.96 |
| D1330 |
|
405 |
399 |
$0.00 |