| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,482 |
1,464 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,066 |
2,044 |
$47K |
| D0272 |
Bitewings - two radiographic images |
991 |
991 |
$19K |
| D1206 |
Topical application of fluoride varnish |
527 |
527 |
$9K |
| D0274 |
Bitewings - four radiographic images |
317 |
308 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
122 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
254 |
$3K |
| D1120 |
Prophylaxis - child |
60 |
60 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |