| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
897 |
895 |
$23K |
| D1110 |
Prophylaxis - adult |
460 |
458 |
$22K |
| D1120 |
Prophylaxis - child |
578 |
577 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
177 |
122 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
113 |
$14K |
| D1206 |
Topical application of fluoride varnish |
540 |
539 |
$13K |
| D0274 |
Bitewings - four radiographic images |
268 |
267 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
82 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
107 |
$2K |
| D0272 |
Bitewings - two radiographic images |
72 |
72 |
$2K |
| D1351 |
Sealant - per tooth |
49 |
14 |
$1K |