| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,505 |
1,490 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
143 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,372 |
1,358 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
383 |
379 |
$14K |
| D0274 |
Bitewings - four radiographic images |
498 |
491 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
692 |
673 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
390 |
383 |
$5K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$231.60 |