| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
963 |
951 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,346 |
1,333 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,197 |
1,185 |
$16K |
| D1120 |
Prophylaxis - child |
385 |
384 |
$9K |
| D0274 |
Bitewings - four radiographic images |
508 |
503 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
119 |
$3K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$340.60 |
| D1351 |
Sealant - per tooth |
49 |
13 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
26 |
$0.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$0.00 |