| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,245 |
877 |
$29K |
| D1120 |
Prophylaxis - child |
1,387 |
1,010 |
$23K |
| D1351 |
Sealant - per tooth |
1,396 |
106 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
659 |
544 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
36 |
$6K |
| D1206 |
Topical application of fluoride varnish |
487 |
296 |
$3K |
| D0274 |
Bitewings - four radiographic images |
114 |
107 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
51 |
51 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
26 |
$1K |
| D8670 |
Periodic orthodontic treatment visit |
14 |
12 |
$1K |