| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,945 |
1,766 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,148 |
995 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,631 |
1,454 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,230 |
1,075 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
634 |
594 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
47 |
$14K |
| D0330 |
Panoramic radiographic image |
358 |
335 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
360 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
66 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
93 |
91 |
$2K |
| D1206 |
Topical application of fluoride varnish |
42 |
41 |
$995.90 |