| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
806 |
789 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
719 |
710 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
50 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
409 |
393 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
25 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
340 |
190 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
106 |
106 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
50 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$2K |