| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,111 |
2,814 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
3,597 |
3,285 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,224 |
2,940 |
$56K |
| D1110 |
Prophylaxis - adult |
1,135 |
1,054 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
448 |
296 |
$43K |
| D0330 |
Panoramic radiographic image |
469 |
439 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
228 |
159 |
$18K |
| D1351 |
Sealant - per tooth |
401 |
66 |
$10K |
| D0274 |
Bitewings - four radiographic images |
314 |
298 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
227 |
$8K |
| D1206 |
Topical application of fluoride varnish |
192 |
186 |
$4K |
| D0272 |
Bitewings - two radiographic images |
210 |
192 |
$4K |
| D2140 |
|
20 |
12 |
$892.65 |
| D1999 |
|
210 |
145 |
$0.00 |