| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,392 |
1,387 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,174 |
1,171 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,210 |
1,205 |
$34K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
36 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
62 |
$4K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$1K |