| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,509 |
1,458 |
$29K |
| D1110 |
Prophylaxis - adult |
662 |
655 |
$25K |
| D1120 |
Prophylaxis - child |
534 |
508 |
$16K |
| D1206 |
Topical application of fluoride varnish |
895 |
856 |
$15K |
| D0274 |
Bitewings - four radiographic images |
224 |
217 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
82 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
126 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$733.59 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$555.65 |