| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,264 |
2,150 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
2,135 |
2,031 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,771 |
1,685 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
136 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
58 |
$4K |
| D1351 |
Sealant - per tooth |
33 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
161 |
145 |
$1K |
| D1206 |
Topical application of fluoride varnish |
48 |
46 |
$1K |
| D0274 |
Bitewings - four radiographic images |
32 |
29 |
$560.38 |