| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,238 |
1,057 |
$76K |
| D1351 |
Sealant - per tooth |
1,788 |
481 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,148 |
971 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
592 |
302 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
390 |
211 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,407 |
1,213 |
$28K |
| D0272 |
Bitewings - two radiographic images |
626 |
554 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,135 |
546 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
373 |
356 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
605 |
548 |
$9K |
| D1110 |
Prophylaxis - adult |
106 |
95 |
$7K |
| D0274 |
Bitewings - four radiographic images |
128 |
115 |
$5K |