| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,259 |
2,105 |
$43K |
| D1120 |
Prophylaxis - child |
1,063 |
1,013 |
$38K |
| D1110 |
Prophylaxis - adult |
615 |
597 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
761 |
723 |
$21K |
| D1351 |
Sealant - per tooth |
406 |
67 |
$8K |
| D0274 |
Bitewings - four radiographic images |
156 |
155 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$4K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
35 |
27 |
$666.99 |
| D9630 |
|
51 |
50 |
$621.00 |