| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,234 |
1,212 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,026 |
1,988 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,596 |
2,541 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
285 |
185 |
$33K |
| D1120 |
Prophylaxis - child |
1,011 |
986 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
64 |
$8K |
| D0274 |
Bitewings - four radiographic images |
235 |
232 |
$7K |
| D4346 |
|
46 |
46 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$3K |
| D1352 |
|
36 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
79 |
$1K |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$1K |
| D1999 |
|
102 |
101 |
$0.00 |
| D0431 |
|
12 |
12 |
$0.00 |