| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
754 |
738 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,370 |
1,326 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,438 |
1,385 |
$20K |
| D1999 |
|
868 |
816 |
$16K |
| D1120 |
Prophylaxis - child |
391 |
371 |
$10K |
| D0274 |
Bitewings - four radiographic images |
211 |
202 |
$4K |
| D0272 |
Bitewings - two radiographic images |
237 |
221 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$929.00 |