| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
737 |
671 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
778 |
719 |
$20K |
| D0274 |
Bitewings - four radiographic images |
689 |
616 |
$19K |
| D1110 |
Prophylaxis - adult |
295 |
269 |
$14K |
| D1351 |
Sealant - per tooth |
523 |
74 |
$13K |
| D1206 |
Topical application of fluoride varnish |
869 |
791 |
$11K |
| D0330 |
Panoramic radiographic image |
202 |
177 |
$7K |
| D0272 |
Bitewings - two radiographic images |
215 |
206 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
107 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
165 |
154 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
24 |
$163.28 |
| D0603 |
|
870 |
822 |
$0.00 |
| D0602 |
|
80 |
74 |
$0.00 |