| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,694 |
1,397 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,999 |
1,624 |
$16K |
| D1110 |
Prophylaxis - adult |
886 |
700 |
$14K |
| D1120 |
Prophylaxis - child |
840 |
669 |
$11K |
| D1999 |
|
972 |
658 |
$8K |
| D0274 |
Bitewings - four radiographic images |
295 |
233 |
$3K |
| D0330 |
Panoramic radiographic image |
117 |
97 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
290 |
222 |
$2K |
| D0272 |
Bitewings - two radiographic images |
53 |
43 |
$742.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$0.00 |