| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,169 |
1,123 |
$40K |
| D1120 |
Prophylaxis - child |
699 |
674 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
819 |
790 |
$24K |
| D1110 |
Prophylaxis - adult |
535 |
507 |
$21K |
| D0330 |
Panoramic radiographic image |
452 |
431 |
$21K |
| D0274 |
Bitewings - four radiographic images |
613 |
574 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
236 |
91 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
413 |
385 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
41 |
$7K |
| D1351 |
Sealant - per tooth |
286 |
52 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
52 |
$1K |