| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,551 |
1,464 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,397 |
1,323 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
775 |
731 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,483 |
1,084 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,171 |
1,082 |
$6K |
| D1351 |
Sealant - per tooth |
79 |
50 |
$5K |
| D0274 |
Bitewings - four radiographic images |
300 |
279 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
26 |
$2K |