| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,634 |
2,555 |
$63K |
| D1120 |
Prophylaxis - child |
1,808 |
1,744 |
$63K |
| D1110 |
Prophylaxis - adult |
1,083 |
1,063 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
241 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,524 |
1,480 |
$33K |
| D0274 |
Bitewings - four radiographic images |
865 |
844 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
204 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
604 |
575 |
$12K |
| D0272 |
Bitewings - two radiographic images |
244 |
224 |
$5K |
| D0330 |
Panoramic radiographic image |
79 |
66 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$3K |