| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,524 |
1,447 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,298 |
1,248 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,084 |
1,063 |
$29K |
| D0274 |
Bitewings - four radiographic images |
247 |
244 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
54 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$722.25 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
14 |
$664.30 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
58 |
$365.25 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$148.02 |