| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,372 |
1,278 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,184 |
2,029 |
$54K |
| D1110 |
Prophylaxis - adult |
866 |
813 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,329 |
1,210 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
37 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
234 |
229 |
$5K |
| D0272 |
Bitewings - two radiographic images |
154 |
145 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
58 |
$2K |
| D1351 |
Sealant - per tooth |
71 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
59 |
55 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$884.40 |