| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
416 |
401 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
308 |
289 |
$12K |
| D0274 |
Bitewings - four radiographic images |
301 |
288 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
363 |
351 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
126 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
40 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
24 |
$3K |
| D1120 |
Prophylaxis - child |
94 |
93 |
$3K |
| D0330 |
Panoramic radiographic image |
25 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
73 |
$1K |