| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,108 |
1,098 |
$31K |
| D1120 |
Prophylaxis - child |
623 |
618 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,235 |
1,225 |
$18K |
| D1110 |
Prophylaxis - adult |
180 |
179 |
$10K |
| D0272 |
Bitewings - two radiographic images |
400 |
396 |
$8K |
| D0274 |
Bitewings - four radiographic images |
198 |
196 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
26 |
$5K |
| D1351 |
Sealant - per tooth |
55 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$700.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$494.48 |
| D0603 |
|
636 |
632 |
$0.00 |
| D0602 |
|
346 |
345 |
$0.00 |