| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,238 |
1,502 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,815 |
1,115 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,991 |
1,358 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
434 |
363 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
36 |
$6K |
| D0274 |
Bitewings - four radiographic images |
285 |
200 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
78 |
$3K |
| D0272 |
Bitewings - two radiographic images |
110 |
77 |
$2K |
| D0330 |
Panoramic radiographic image |
52 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
93 |
$1K |