| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,231 |
1,134 |
$20K |
| D1120 |
Prophylaxis - child |
513 |
469 |
$12K |
| D1110 |
Prophylaxis - adult |
364 |
337 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
922 |
845 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
59 |
$7K |
| D1999 |
|
262 |
205 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
27 |
$1K |
| D1206 |
Topical application of fluoride varnish |
27 |
26 |
$671.20 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$667.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$316.80 |