| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
829 |
794 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
779 |
746 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
457 |
442 |
$12K |
| D1351 |
Sealant - per tooth |
43 |
29 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
37 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
44 |
37 |
$3K |
| D0272 |
Bitewings - two radiographic images |
263 |
257 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
175 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
24 |
$439.40 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
13 |
$431.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
15 |
$178.60 |