| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,433 |
2,238 |
$58K |
| D1110 |
Prophylaxis - adult |
1,129 |
1,044 |
$40K |
| D1120 |
Prophylaxis - child |
960 |
904 |
$25K |
| D1206 |
Topical application of fluoride varnish |
903 |
858 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
114 |
51 |
$13K |
| D0274 |
Bitewings - four radiographic images |
166 |
158 |
$5K |
| D0272 |
Bitewings - two radiographic images |
102 |
99 |
$2K |
| D1351 |
Sealant - per tooth |
42 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
57 |
$897.59 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
24 |
$399.60 |