| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,025 |
1,965 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,005 |
1,942 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,041 |
1,980 |
$52K |
| D1351 |
Sealant - per tooth |
153 |
53 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
64 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
790 |
757 |
$5K |
| D0274 |
Bitewings - four radiographic images |
183 |
172 |
$3K |
| D0272 |
Bitewings - two radiographic images |
269 |
256 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
378 |
363 |
$2K |
| D0330 |
Panoramic radiographic image |
55 |
54 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$259.20 |