| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,026 |
1,022 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,160 |
1,157 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,174 |
808 |
$19K |
| D0274 |
Bitewings - four radiographic images |
662 |
659 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
96 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
871 |
866 |
$7K |
| D1330 |
|
541 |
541 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
67 |
$4K |
| D1320 |
|
206 |
206 |
$4K |
| D1310 |
|
278 |
278 |
$3K |
| D1206 |
Topical application of fluoride varnish |
164 |
164 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$224.64 |