| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
244 |
239 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
342 |
326 |
$7K |
| D1120 |
Prophylaxis - child |
123 |
114 |
$3K |
| D0274 |
Bitewings - four radiographic images |
92 |
91 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
27 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
63 |
$1K |
| D1206 |
Topical application of fluoride varnish |
69 |
68 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$887.25 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$308.23 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
45 |
$302.34 |