| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
797 |
788 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
204 |
$20K |
| D1110 |
Prophylaxis - adult |
714 |
707 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
492 |
$17K |
| D0274 |
Bitewings - four radiographic images |
895 |
888 |
$17K |
| D0330 |
Panoramic radiographic image |
520 |
509 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
309 |
125 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,232 |
1,210 |
$13K |
| D1120 |
Prophylaxis - child |
521 |
511 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
81 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
56 |
$459.00 |