| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
322 |
314 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
355 |
352 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
252 |
243 |
$4K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
51 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
142 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$1K |