| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
904 |
817 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,487 |
1,332 |
$26K |
| D1999 |
|
1,419 |
1,136 |
$22K |
| D1120 |
Prophylaxis - child |
688 |
590 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,260 |
1,112 |
$16K |
| D0274 |
Bitewings - four radiographic images |
279 |
254 |
$5K |
| D1206 |
Topical application of fluoride varnish |
251 |
224 |
$5K |
| D0272 |
Bitewings - two radiographic images |
248 |
204 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
119 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$690.15 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
15 |
$198.75 |