| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,098 |
3,678 |
$195K |
| D0120 |
Periodic oral evaluation - established patient |
3,134 |
2,985 |
$88K |
| D1206 |
Topical application of fluoride varnish |
966 |
928 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,058 |
2,679 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
692 |
657 |
$20K |
| D0272 |
Bitewings - two radiographic images |
861 |
725 |
$14K |
| D0330 |
Panoramic radiographic image |
122 |
109 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
32 |
16 |
$3K |
| D1351 |
Sealant - per tooth |
125 |
24 |
$3K |
| D0999 |
Unspecified diagnostic procedure, by report |
64 |
64 |
$2K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$1K |
| D9420 |
|
12 |
12 |
$491.88 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$319.35 |