| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,316 |
1,300 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,553 |
1,532 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
51 |
$15K |
| D0274 |
Bitewings - four radiographic images |
424 |
419 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
636 |
613 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
25 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
297 |
$4K |
| D1120 |
Prophylaxis - child |
121 |
115 |
$4K |
| D1206 |
Topical application of fluoride varnish |
210 |
210 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
226 |
215 |
$3K |