| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
7,816 |
7,816 |
$182K |
| D1110 |
Prophylaxis - adult |
3,632 |
3,632 |
$161K |
| D0274 |
Bitewings - four radiographic images |
3,899 |
3,899 |
$89K |
| D0220 |
Intraoral - periapical first radiographic image |
8,428 |
8,380 |
$87K |
| D1120 |
Prophylaxis - child |
1,726 |
1,726 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,657 |
7,644 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,260 |
3,260 |
$39K |
| D0272 |
Bitewings - two radiographic images |
676 |
676 |
$9K |
| D1351 |
Sealant - per tooth |
38 |
38 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
40 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
25 |
$2K |