| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,029 |
1,004 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
898 |
881 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
477 |
467 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
125 |
$11K |
| D0274 |
Bitewings - four radiographic images |
438 |
430 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,292 |
1,248 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
304 |
298 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,178 |
1,142 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
182 |
171 |
$3K |
| D0272 |
Bitewings - two radiographic images |
169 |
164 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$726.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$709.55 |