| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,398 |
2,000 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,264 |
1,201 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,331 |
1,951 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
305 |
145 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,055 |
854 |
$22K |
| D0330 |
Panoramic radiographic image |
579 |
452 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
764 |
447 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
352 |
260 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
75 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$74.97 |