| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
551 |
515 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,060 |
1,026 |
$26K |
| D1206 |
Topical application of fluoride varnish |
989 |
961 |
$21K |
| D1120 |
Prophylaxis - child |
410 |
401 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
58 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
730 |
680 |
$12K |
| D0274 |
Bitewings - four radiographic images |
202 |
195 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
492 |
461 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D9630 |
|
13 |
13 |
$195.14 |