| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,821 |
2,349 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,740 |
3,135 |
$90K |
| D1110 |
Prophylaxis - adult |
1,638 |
1,378 |
$82K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,955 |
3,319 |
$80K |
| D0272 |
Bitewings - two radiographic images |
1,618 |
1,328 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
201 |
$29K |
| D0330 |
Panoramic radiographic image |
113 |
74 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
39 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$350.00 |