| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
408 |
373 |
$11K |
| D1120 |
Prophylaxis - child |
273 |
242 |
$11K |
| D1110 |
Prophylaxis - adult |
100 |
96 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
94 |
89 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
43 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$617.00 |
| D0274 |
Bitewings - four radiographic images |
34 |
29 |
$557.70 |