| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
7,163 |
7,163 |
$164K |
| D1110 |
Prophylaxis - adult |
3,343 |
3,342 |
$146K |
| D1120 |
Prophylaxis - child |
2,812 |
2,812 |
$99K |
| D0274 |
Bitewings - four radiographic images |
3,338 |
3,338 |
$76K |
| D0220 |
Intraoral - periapical first radiographic image |
7,248 |
7,217 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,527 |
3,527 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
606 |
487 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,787 |
6,780 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,596 |
1,596 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
426 |
355 |
$19K |
| D1351 |
Sealant - per tooth |
16 |
13 |
$1K |