| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,557 |
1,547 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,595 |
1,583 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
404 |
273 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,357 |
1,348 |
$26K |
| D1110 |
Prophylaxis - adult |
436 |
435 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
315 |
236 |
$20K |
| D0272 |
Bitewings - two radiographic images |
893 |
890 |
$19K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$3K |
| D1206 |
Topical application of fluoride varnish |
133 |
133 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
22 |
15 |
$190.97 |