| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,047 |
972 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,101 |
1,036 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,312 |
1,230 |
$22K |
| D1351 |
Sealant - per tooth |
660 |
139 |
$20K |
| D1110 |
Prophylaxis - adult |
438 |
404 |
$20K |
| D0274 |
Bitewings - four radiographic images |
532 |
497 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
88 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
139 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
42 |
$5K |
| D0330 |
Panoramic radiographic image |
122 |
105 |
$4K |