| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
941 |
922 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,506 |
1,484 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,291 |
1,271 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
492 |
214 |
$28K |
| D1120 |
Prophylaxis - child |
627 |
618 |
$21K |
| D0330 |
Panoramic radiographic image |
421 |
411 |
$20K |
| D0274 |
Bitewings - four radiographic images |
582 |
575 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
82 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
466 |
407 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
186 |
$5K |
| D1351 |
Sealant - per tooth |
139 |
45 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |