| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
862 |
790 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
238 |
175 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
647 |
594 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
475 |
435 |
$12K |
| D1351 |
Sealant - per tooth |
144 |
87 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
74 |
$4K |
| D0274 |
Bitewings - four radiographic images |
189 |
173 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
426 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
113 |
$2K |
| D0272 |
Bitewings - two radiographic images |
182 |
167 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
397 |
366 |
$1K |