| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
514 |
476 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
595 |
550 |
$12K |
| D1206 |
Topical application of fluoride varnish |
481 |
450 |
$9K |
| D1120 |
Prophylaxis - child |
264 |
253 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
361 |
343 |
$7K |
| D0274 |
Bitewings - four radiographic images |
191 |
178 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
146 |
$3K |
| D0330 |
Panoramic radiographic image |
88 |
82 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$984.58 |