| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,438 |
1,957 |
$41K |
| D1110 |
Prophylaxis - adult |
1,207 |
930 |
$39K |
| D1120 |
Prophylaxis - child |
1,146 |
919 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,832 |
1,478 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
818 |
603 |
$19K |
| D0330 |
Panoramic radiographic image |
368 |
331 |
$18K |
| D1351 |
Sealant - per tooth |
427 |
34 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
56 |
$8K |
| D0272 |
Bitewings - two radiographic images |
330 |
254 |
$5K |
| D5410 |
|
15 |
13 |
$891.00 |
| D5422 |
|
12 |
12 |
$385.36 |