| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,626 |
1,601 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
1,323 |
1,298 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,495 |
1,470 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
58 |
$12K |
| D0274 |
Bitewings - four radiographic images |
78 |
77 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
34 |
$608.19 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
29 |
$499.80 |