| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
905 |
891 |
$22K |
| D1110 |
Prophylaxis - adult |
431 |
425 |
$12K |
| D1120 |
Prophylaxis - child |
521 |
514 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
918 |
904 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
91 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
51 |
$5K |
| D0272 |
Bitewings - two radiographic images |
317 |
315 |
$5K |
| D0274 |
Bitewings - four radiographic images |
130 |
127 |
$3K |
| D1351 |
Sealant - per tooth |
55 |
15 |
$1K |