| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
914 |
835 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
749 |
685 |
$18K |
| D0274 |
Bitewings - four radiographic images |
336 |
303 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
232 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
26 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
54 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$356.86 |