| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
653 |
581 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
43 |
$11K |
| D1120 |
Prophylaxis - child |
340 |
304 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
753 |
673 |
$9K |
| D1351 |
Sealant - per tooth |
341 |
60 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
713 |
627 |
$7K |
| D1110 |
Prophylaxis - adult |
146 |
134 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
691 |
590 |
$6K |
| D0272 |
Bitewings - two radiographic images |
276 |
251 |
$6K |
| D0274 |
Bitewings - four radiographic images |
62 |
59 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$1K |
| D0603 |
|
330 |
311 |
$0.00 |
| D0602 |
|
393 |
363 |
$0.00 |