| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,382 |
2,381 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
2,966 |
2,958 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
728 |
320 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
380 |
264 |
$28K |
| D0330 |
Panoramic radiographic image |
671 |
670 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,460 |
1,459 |
$18K |
| D0274 |
Bitewings - four radiographic images |
737 |
736 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,001 |
984 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
521 |
506 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
45 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
89 |
$1K |