| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
635 |
574 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
338 |
312 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
332 |
298 |
$5K |
| D1206 |
Topical application of fluoride varnish |
209 |
198 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
40 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
38 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
166 |
136 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
28 |
$525.48 |