| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
375 |
374 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
585 |
584 |
$10K |
| D1120 |
Prophylaxis - child |
268 |
268 |
$7K |
| D0274 |
Bitewings - four radiographic images |
366 |
366 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
786 |
776 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
677 |
662 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
322 |
322 |
$3K |
| D0272 |
Bitewings - two radiographic images |
130 |
130 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$900.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$605.00 |