| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,530 |
1,440 |
$41K |
| D1120 |
Prophylaxis - child |
1,059 |
988 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
240 |
136 |
$12K |
| D1110 |
Prophylaxis - adult |
497 |
468 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,101 |
1,032 |
$11K |
| D0272 |
Bitewings - two radiographic images |
781 |
726 |
$9K |
| D0274 |
Bitewings - four radiographic images |
483 |
458 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
133 |
$4K |
| D1206 |
Topical application of fluoride varnish |
376 |
360 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
40 |
$3K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$120.00 |