| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,772 |
1,742 |
$77K |
| D1206 |
Topical application of fluoride varnish |
2,624 |
2,581 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,111 |
2,082 |
$63K |
| D1110 |
Prophylaxis - adult |
704 |
694 |
$43K |
| D0274 |
Bitewings - four radiographic images |
826 |
813 |
$19K |
| D0272 |
Bitewings - two radiographic images |
844 |
832 |
$13K |
| D1351 |
Sealant - per tooth |
359 |
51 |
$12K |
| D1330 |
|
1,049 |
1,031 |
$7K |
| D0330 |
Panoramic radiographic image |
154 |
154 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
96 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$3K |