| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,427 |
1,405 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,019 |
1,967 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,553 |
1,515 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
268 |
$14K |
| D1110 |
Prophylaxis - adult |
202 |
202 |
$12K |
| D0274 |
Bitewings - four radiographic images |
294 |
293 |
$7K |
| D0330 |
Panoramic radiographic image |
104 |
103 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
173 |
166 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
156 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
142 |
142 |
$953.68 |