| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,635 |
1,527 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,848 |
1,729 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,736 |
1,632 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
118 |
$27K |
| D0272 |
Bitewings - two radiographic images |
541 |
521 |
$13K |
| D1110 |
Prophylaxis - adult |
68 |
60 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
33 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
27 |
$480.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$467.00 |