| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,283 |
2,154 |
$93K |
| D1351 |
Sealant - per tooth |
665 |
349 |
$56K |
| D1206 |
Topical application of fluoride varnish |
2,140 |
2,024 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,290 |
1,183 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
879 |
817 |
$24K |
| D0274 |
Bitewings - four radiographic images |
446 |
418 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
66 |
$5K |
| D0272 |
Bitewings - two radiographic images |
509 |
471 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
78 |
74 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
24 |
$1K |