| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,402 |
1,402 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,739 |
2,739 |
$63K |
| D1120 |
Prophylaxis - child |
1,486 |
1,486 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,461 |
1,461 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,186 |
2,186 |
$35K |
| D0272 |
Bitewings - two radiographic images |
828 |
828 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
69 |
$12K |
| D1206 |
Topical application of fluoride varnish |
689 |
689 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
540 |
537 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
526 |
523 |
$6K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
25 |
$3K |