| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,721 |
2,709 |
$65K |
| D1120 |
Prophylaxis - child |
1,999 |
1,989 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,196 |
2,133 |
$48K |
| D1110 |
Prophylaxis - adult |
949 |
945 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,006 |
989 |
$27K |
| D1999 |
|
2,091 |
2,007 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,179 |
1,178 |
$16K |
| D1351 |
Sealant - per tooth |
364 |
94 |
$10K |
| D0274 |
Bitewings - four radiographic images |
491 |
489 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
41 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
143 |
$3K |