| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,523 |
5,255 |
$136K |
| D1110 |
Prophylaxis - adult |
2,258 |
2,160 |
$81K |
| D1120 |
Prophylaxis - child |
1,954 |
1,865 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
194 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,860 |
1,791 |
$30K |
| D0274 |
Bitewings - four radiographic images |
402 |
389 |
$12K |
| D1206 |
Topical application of fluoride varnish |
484 |
447 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
52 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
84 |
$4K |
| D0272 |
Bitewings - two radiographic images |
191 |
188 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
12 |
$675.72 |