| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,204 |
1,115 |
$25K |
| D1120 |
Prophylaxis - child |
808 |
754 |
$23K |
| D1110 |
Prophylaxis - adult |
451 |
398 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
584 |
544 |
$10K |
| D0330 |
Panoramic radiographic image |
131 |
108 |
$4K |
| D0272 |
Bitewings - two radiographic images |
164 |
151 |
$3K |
| D1351 |
Sealant - per tooth |
115 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
107 |
92 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
43 |
$1K |
| D1206 |
Topical application of fluoride varnish |
75 |
55 |
$1K |