| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,259 |
5,020 |
$209K |
| D0120 |
Periodic oral evaluation - established patient |
5,426 |
5,159 |
$147K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,225 |
4,985 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
242 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,160 |
1,095 |
$11K |
| D0274 |
Bitewings - four radiographic images |
489 |
479 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
150 |
146 |
$4K |
| D1351 |
Sealant - per tooth |
30 |
27 |
$4K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$1K |