| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
811 |
791 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,206 |
1,163 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,276 |
1,235 |
$32K |
| D1120 |
Prophylaxis - child |
592 |
572 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
57 |
$16K |
| D1351 |
Sealant - per tooth |
411 |
106 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
242 |
235 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
41 |
$9K |
| D0274 |
Bitewings - four radiographic images |
238 |
225 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
184 |
176 |
$7K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$902.72 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
12 |
$248.69 |