| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
759 |
755 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,029 |
1,026 |
$28K |
| D0272 |
Bitewings - two radiographic images |
462 |
461 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
204 |
204 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
148 |
129 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
117 |
$2K |
| D1120 |
Prophylaxis - child |
35 |
35 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |