| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,494 |
1,458 |
$25K |
| D1110 |
Prophylaxis - adult |
561 |
541 |
$23K |
| D1120 |
Prophylaxis - child |
787 |
770 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,037 |
1,015 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$4K |
| D0274 |
Bitewings - four radiographic images |
129 |
122 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$550.15 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
15 |
$178.88 |