| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,967 |
1,923 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,365 |
2,309 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
572 |
256 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,630 |
1,593 |
$27K |
| D0274 |
Bitewings - four radiographic images |
664 |
654 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
92 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
145 |
131 |
$4K |
| D0330 |
Panoramic radiographic image |
72 |
67 |
$4K |
| D1120 |
Prophylaxis - child |
105 |
104 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$350.68 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$219.93 |