| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
266 |
258 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
400 |
382 |
$9K |
| D1206 |
Topical application of fluoride varnish |
326 |
309 |
$6K |
| D0274 |
Bitewings - four radiographic images |
227 |
219 |
$5K |
| D1120 |
Prophylaxis - child |
173 |
161 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
41 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
44 |
$840.50 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$497.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$380.25 |