| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
942 |
928 |
$53K |
| D1206 |
Topical application of fluoride varnish |
1,227 |
1,200 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
874 |
854 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
107 |
$24K |
| D0274 |
Bitewings - four radiographic images |
379 |
368 |
$21K |
| D0272 |
Bitewings - two radiographic images |
515 |
501 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
171 |
$15K |
| D1110 |
Prophylaxis - adult |
142 |
138 |
$12K |
| D0330 |
Panoramic radiographic image |
78 |
78 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$4K |
| D1351 |
Sealant - per tooth |
46 |
13 |
$2K |