| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
587 |
504 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
566 |
457 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
602 |
541 |
$9K |
| D0330 |
Panoramic radiographic image |
329 |
271 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
319 |
304 |
$7K |
| D0274 |
Bitewings - four radiographic images |
660 |
567 |
$7K |
| D1120 |
Prophylaxis - child |
146 |
136 |
$3K |
| D9992 |
|
243 |
215 |
$2K |
| D1351 |
Sealant - per tooth |
75 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$966.19 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$681.85 |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$421.89 |
| D1206 |
Topical application of fluoride varnish |
15 |
14 |
$183.64 |