| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
470 |
458 |
$10K |
| D1120 |
Prophylaxis - child |
327 |
317 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
578 |
561 |
$10K |
| D1110 |
Prophylaxis - adult |
170 |
167 |
$7K |
| D9248 |
|
31 |
30 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$309.14 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$267.18 |