| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,306 |
1,305 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,811 |
1,811 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,672 |
1,672 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
337 |
212 |
$29K |
| D1110 |
Prophylaxis - adult |
410 |
410 |
$19K |
| D0274 |
Bitewings - four radiographic images |
534 |
534 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
90 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
750 |
730 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
418 |
227 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |