| Code | Description | Claims | Beneficiaries | Total Paid |
| D0120 |
Periodic oral evaluation - established patient |
1,971 |
1,897 |
$48K |
| D1110 |
Prophylaxis - adult |
1,010 |
976 |
$36K |
| D1120 |
Prophylaxis - child |
901 |
867 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,441 |
1,391 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,410 |
1,328 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
986 |
933 |
$12K |
| D0274 |
Bitewings - four radiographic images |
234 |
233 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
25 |
$6K |
| D0330 |
Panoramic radiographic image |
109 |
107 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
29 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
93 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$442.22 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$135.45 |
| D1999 |
|
123 |
110 |
$0.00 |