| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,291 |
2,290 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,818 |
2,816 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,642 |
2,640 |
$40K |
| D0272 |
Bitewings - two radiographic images |
2,382 |
2,380 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,715 |
2,707 |
$29K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
130 |
112 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
97 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
867 |
867 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
78 |
$3K |
| D1120 |
Prophylaxis - child |
77 |
77 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
25 |
$2K |