| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,558 |
1,541 |
$35K |
| D1120 |
Prophylaxis - child |
980 |
969 |
$30K |
| D1110 |
Prophylaxis - adult |
672 |
657 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
776 |
758 |
$13K |
| D0272 |
Bitewings - two radiographic images |
556 |
550 |
$11K |
| D1206 |
Topical application of fluoride varnish |
480 |
477 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
29 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
44 |
$1K |
| D1351 |
Sealant - per tooth |
47 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$837.75 |