| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,263 |
2,143 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
2,089 |
1,981 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,492 |
1,409 |
$38K |
| D0274 |
Bitewings - four radiographic images |
448 |
416 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
57 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
82 |
$2K |
| D0272 |
Bitewings - two radiographic images |
126 |
112 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
73 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
155 |
$886.80 |