| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
866 |
860 |
$40K |
| D1120 |
Prophylaxis - child |
1,098 |
1,095 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,740 |
1,733 |
$34K |
| D9630 |
|
1,296 |
1,294 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,237 |
1,231 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
203 |
138 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
503 |
503 |
$10K |
| D0274 |
Bitewings - four radiographic images |
308 |
307 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
56 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
200 |
$6K |
| D0330 |
Panoramic radiographic image |
93 |
93 |
$5K |
| D0272 |
Bitewings - two radiographic images |
74 |
74 |
$1K |