| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,905 |
1,870 |
$45K |
| D1120 |
Prophylaxis - child |
786 |
773 |
$25K |
| D1206 |
Topical application of fluoride varnish |
815 |
803 |
$15K |
| D1110 |
Prophylaxis - adult |
313 |
307 |
$13K |
| D0274 |
Bitewings - four radiographic images |
123 |
122 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$881.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
40 |
$845.67 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$256.71 |