| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,401 |
2,342 |
$57K |
| D1110 |
Prophylaxis - adult |
1,571 |
1,529 |
$55K |
| D1120 |
Prophylaxis - child |
736 |
719 |
$18K |
| D0274 |
Bitewings - four radiographic images |
528 |
518 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
809 |
790 |
$13K |
| D1206 |
Topical application of fluoride varnish |
593 |
575 |
$9K |
| D0272 |
Bitewings - two radiographic images |
130 |
123 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$847.69 |