| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,366 |
2,109 |
$55K |
| D1110 |
Prophylaxis - adult |
1,477 |
1,361 |
$52K |
| D1120 |
Prophylaxis - child |
868 |
800 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,364 |
1,215 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,003 |
884 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
124 |
$12K |
| D0274 |
Bitewings - four radiographic images |
271 |
239 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
71 |
$3K |
| D0272 |
Bitewings - two radiographic images |
64 |
62 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
13 |
$743.40 |