| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
361 |
335 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
526 |
488 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
687 |
624 |
$9K |
| D1120 |
Prophylaxis - child |
176 |
161 |
$4K |
| D1206 |
Topical application of fluoride varnish |
145 |
140 |
$3K |
| D0274 |
Bitewings - four radiographic images |
108 |
101 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
42 |
$1K |
| D1999 |
|
107 |
91 |
$860.00 |
| D0272 |
Bitewings - two radiographic images |
62 |
56 |
$767.70 |