| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,598 |
1,597 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,025 |
2,025 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,818 |
1,817 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
428 |
297 |
$38K |
| D1110 |
Prophylaxis - adult |
577 |
577 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
138 |
$23K |
| D0274 |
Bitewings - four radiographic images |
410 |
410 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
408 |
404 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
90 |
$6K |
| D0272 |
Bitewings - two radiographic images |
246 |
246 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
317 |
137 |
$3K |