| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
741 |
712 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
54 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
799 |
772 |
$11K |
| D0274 |
Bitewings - four radiographic images |
352 |
335 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
731 |
694 |
$8K |
| D1110 |
Prophylaxis - adult |
170 |
162 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
715 |
679 |
$8K |
| D1120 |
Prophylaxis - child |
164 |
156 |
$5K |
| D1351 |
Sealant - per tooth |
47 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
28 |
26 |
$549.25 |
| D1330 |
|
15 |
13 |
$24.50 |
| D0603 |
|
833 |
803 |
$0.00 |