| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,269 |
1,247 |
$57K |
| D1120 |
Prophylaxis - child |
1,022 |
1,005 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,963 |
1,923 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,059 |
2,020 |
$33K |
| D0274 |
Bitewings - four radiographic images |
671 |
658 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
545 |
536 |
$14K |
| D0330 |
Panoramic radiographic image |
220 |
220 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
55 |
$4K |
| D0272 |
Bitewings - two radiographic images |
237 |
228 |
$4K |
| D1351 |
Sealant - per tooth |
114 |
20 |
$2K |
| D1999 |
|
65 |
60 |
$0.00 |