| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
7,500 |
7,413 |
$234K |
| D1110 |
Prophylaxis - adult |
2,634 |
2,603 |
$143K |
| D1120 |
Prophylaxis - child |
3,351 |
3,318 |
$127K |
| D1206 |
Topical application of fluoride varnish |
2,623 |
2,594 |
$49K |
| D0272 |
Bitewings - two radiographic images |
678 |
674 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
981 |
972 |
$17K |
| D1354 |
|
246 |
78 |
$6K |
| D0274 |
Bitewings - four radiographic images |
137 |
135 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
39 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
32 |
12 |
$934.50 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$478.32 |
| D0603 |
|
16 |
13 |
$0.00 |