| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,556 |
1,548 |
$45K |
| D1110 |
Prophylaxis - adult |
752 |
743 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,264 |
1,262 |
$29K |
| D1351 |
Sealant - per tooth |
800 |
126 |
$21K |
| D1120 |
Prophylaxis - child |
536 |
536 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
62 |
$12K |
| D0274 |
Bitewings - four radiographic images |
246 |
242 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$1K |