| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,076 |
2,050 |
$111K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
934 |
405 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,099 |
2,077 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,041 |
1,023 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
529 |
525 |
$15K |
| D1120 |
Prophylaxis - child |
198 |
194 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
130 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
79 |
$1K |