| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
735 |
703 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
809 |
781 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
201 |
100 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
385 |
375 |
$6K |
| D0274 |
Bitewings - four radiographic images |
186 |
181 |
$3K |
| D1120 |
Prophylaxis - child |
152 |
150 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
51 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$972.00 |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
136 |
$674.00 |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$490.50 |