| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
971 |
956 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
223 |
159 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,254 |
1,233 |
$23K |
| D1120 |
Prophylaxis - child |
436 |
429 |
$23K |
| D1110 |
Prophylaxis - adult |
120 |
120 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
235 |
218 |
$4K |
| D0274 |
Bitewings - four radiographic images |
88 |
87 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
74 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$2K |