| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,454 |
3,410 |
$94K |
| D1110 |
Prophylaxis - adult |
1,785 |
1,755 |
$84K |
| D1120 |
Prophylaxis - child |
2,216 |
2,182 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,686 |
2,647 |
$53K |
| D0272 |
Bitewings - two radiographic images |
1,689 |
1,662 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
53 |
$11K |
| D0330 |
Panoramic radiographic image |
195 |
192 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
124 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
53 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
54 |
30 |
$4K |