| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,137 |
1,087 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,140 |
1,100 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
356 |
246 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
885 |
849 |
$22K |
| D1351 |
Sealant - per tooth |
347 |
115 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,123 |
1,055 |
$6K |
| D0272 |
Bitewings - two radiographic images |
528 |
503 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,083 |
1,018 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
32 |
$2K |
| D0270 |
|
339 |
331 |
$2K |
| D0274 |
Bitewings - four radiographic images |
16 |
13 |
$225.12 |