| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
696 |
630 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
820 |
748 |
$12K |
| D2335 |
|
81 |
37 |
$7K |
| D0274 |
Bitewings - four radiographic images |
305 |
261 |
$5K |
| D1120 |
Prophylaxis - child |
279 |
251 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
149 |
136 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
14 |
$1K |
| D2394 |
|
13 |
12 |
$995.02 |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
81 |
$350.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$270.00 |