| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
475 |
464 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
723 |
703 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
239 |
66 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
523 |
493 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
350 |
350 |
$5K |
| D1206 |
Topical application of fluoride varnish |
280 |
260 |
$5K |
| D0274 |
Bitewings - four radiographic images |
144 |
136 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
15 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
410 |
367 |
$3K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$731.76 |