| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,362 |
3,331 |
$170K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,036 |
4,001 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
3,837 |
3,798 |
$111K |
| D1110 |
Prophylaxis - adult |
311 |
310 |
$22K |
| D0272 |
Bitewings - two radiographic images |
328 |
327 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
131 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$598.00 |