| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
953 |
943 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
697 |
689 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
460 |
454 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
309 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
298 |
283 |
$1K |
| D0274 |
Bitewings - four radiographic images |
47 |
41 |
$917.24 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$336.00 |