| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,540 |
1,481 |
$34K |
| D1120 |
Prophylaxis - child |
933 |
900 |
$30K |
| D1110 |
Prophylaxis - adult |
615 |
583 |
$25K |
| D1206 |
Topical application of fluoride varnish |
868 |
836 |
$16K |
| D0274 |
Bitewings - four radiographic images |
275 |
265 |
$9K |
| D0330 |
Panoramic radiographic image |
69 |
64 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
69 |
64 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
135 |
130 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$192.36 |