| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,757 |
1,627 |
$47K |
| D1120 |
Prophylaxis - child |
1,152 |
1,073 |
$44K |
| D1110 |
Prophylaxis - adult |
603 |
566 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,062 |
1,032 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
771 |
671 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
28 |
$5K |
| D0330 |
Panoramic radiographic image |
60 |
57 |
$4K |
| D0274 |
Bitewings - four radiographic images |
94 |
86 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
67 |
15 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$820.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$579.46 |
| D1320 |
|
13 |
13 |
$414.31 |