| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,696 |
1,594 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,536 |
1,449 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,546 |
1,448 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
405 |
284 |
$22K |
| D0274 |
Bitewings - four radiographic images |
272 |
245 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
919 |
832 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
754 |
681 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
67 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
151 |
143 |
$1K |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$574.00 |