| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
778 |
769 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
910 |
899 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
102 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
53 |
$8K |
| D0274 |
Bitewings - four radiographic images |
346 |
341 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
452 |
445 |
$6K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
150 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
39 |
$1K |