| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,290 |
1,201 |
$27K |
| D1110 |
Prophylaxis - adult |
628 |
593 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,125 |
1,053 |
$20K |
| D1120 |
Prophylaxis - child |
495 |
475 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
38 |
37 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
25 |
$796.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$721.26 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$541.02 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
25 |
$288.54 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$280.50 |