| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,027 |
1,012 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,331 |
1,307 |
$31K |
| D1120 |
Prophylaxis - child |
519 |
513 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
788 |
772 |
$16K |
| D1206 |
Topical application of fluoride varnish |
470 |
464 |
$10K |
| D0274 |
Bitewings - four radiographic images |
274 |
267 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
69 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
115 |
$1K |
| D0272 |
Bitewings - two radiographic images |
30 |
29 |
$537.37 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
12 |
$156.20 |
| D1999 |
|
320 |
300 |
$0.00 |