| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
707 |
691 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
330 |
320 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
660 |
593 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
414 |
410 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
44 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
227 |
225 |
$6K |
| D0274 |
Bitewings - four radiographic images |
161 |
156 |
$6K |
| D1120 |
Prophylaxis - child |
109 |
107 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
401 |
357 |
$5K |
| D9110 |
|
84 |
75 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
53 |
$3K |