| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,170 |
2,170 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,997 |
2,997 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
962 |
379 |
$34K |
| D0274 |
Bitewings - four radiographic images |
2,047 |
2,047 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
643 |
643 |
$25K |
| D1120 |
Prophylaxis - child |
668 |
668 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,821 |
1,820 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
295 |
162 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,252 |
1,252 |
$11K |
| D2394 |
|
108 |
82 |
$9K |
| D2750 |
|
24 |
18 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,437 |
1,435 |
$7K |