| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
248 |
205 |
$7K |
| D0350 |
|
534 |
158 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
289 |
242 |
$4K |
| D0274 |
Bitewings - four radiographic images |
167 |
141 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
34 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
96 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
56 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$810.00 |
| D0220 |
Intraoral - periapical first radiographic image |
191 |
147 |
$775.00 |
| D1120 |
Prophylaxis - child |
30 |
30 |
$600.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
40 |
$240.00 |