| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,232 |
2,656 |
$70K |
| D1120 |
Prophylaxis - child |
1,963 |
1,566 |
$62K |
| D1110 |
Prophylaxis - adult |
1,140 |
1,008 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,897 |
2,340 |
$51K |
| D0330 |
Panoramic radiographic image |
126 |
99 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
43 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
25 |
$4K |
| D0274 |
Bitewings - four radiographic images |
85 |
67 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
77 |
$3K |