| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
583 |
583 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
888 |
888 |
$17K |
| D0274 |
Bitewings - four radiographic images |
658 |
658 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
727 |
726 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
26 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
165 |
165 |
$2K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
176 |
176 |
$2K |