| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,050 |
1,029 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
505 |
311 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,213 |
1,194 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
278 |
175 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
374 |
370 |
$6K |
| D0274 |
Bitewings - four radiographic images |
227 |
222 |
$5K |
| D1120 |
Prophylaxis - child |
145 |
138 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
111 |
$3K |
| D0330 |
Panoramic radiographic image |
37 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
381 |
363 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
42 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
173 |
157 |
$979.40 |