| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,390 |
1,322 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,259 |
1,195 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,146 |
1,090 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
121 |
111 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
44 |
$268.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
44 |
$177.28 |