| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,724 |
2,616 |
$50K |
| D1110 |
Prophylaxis - adult |
1,307 |
1,255 |
$44K |
| D1120 |
Prophylaxis - child |
1,161 |
1,115 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,049 |
1,972 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,347 |
1,293 |
$22K |
| D0330 |
Panoramic radiographic image |
207 |
198 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
24 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$263.60 |