| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,106 |
4,778 |
$126K |
| D1120 |
Prophylaxis - child |
3,678 |
3,464 |
$96K |
| D1206 |
Topical application of fluoride varnish |
5,267 |
4,952 |
$81K |
| D1110 |
Prophylaxis - adult |
1,537 |
1,452 |
$56K |
| D0272 |
Bitewings - two radiographic images |
1,719 |
1,628 |
$30K |
| D8670 |
Periodic orthodontic treatment visit |
282 |
269 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
25 |
$5K |
| D0330 |
Panoramic radiographic image |
85 |
83 |
$4K |
| D0274 |
Bitewings - four radiographic images |
136 |
133 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
99 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
15 |
$3K |
| D1351 |
Sealant - per tooth |
51 |
15 |
$874.17 |