| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,733 |
3,430 |
$130K |
| D1206 |
Topical application of fluoride varnish |
5,320 |
4,842 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
3,937 |
3,601 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
645 |
400 |
$89K |
| D0274 |
Bitewings - four radiographic images |
1,899 |
1,697 |
$59K |
| D0272 |
Bitewings - two radiographic images |
1,308 |
1,206 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
334 |
197 |
$21K |
| D1110 |
Prophylaxis - adult |
415 |
358 |
$18K |
| D0330 |
Panoramic radiographic image |
216 |
182 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
212 |
$7K |
| D1310 |
|
148 |
147 |
$5K |
| D1351 |
Sealant - per tooth |
82 |
32 |
$2K |