| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,305 |
2,212 |
$48K |
| D1110 |
Prophylaxis - adult |
1,057 |
1,015 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
580 |
307 |
$41K |
| D1120 |
Prophylaxis - child |
1,135 |
1,093 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,374 |
1,333 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
219 |
140 |
$15K |
| D0274 |
Bitewings - four radiographic images |
464 |
452 |
$13K |
| D0272 |
Bitewings - two radiographic images |
534 |
518 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
106 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$469.60 |