| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,290 |
1,244 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
174 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
907 |
872 |
$15K |
| D0274 |
Bitewings - four radiographic images |
793 |
772 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
219 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
26 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
235 |
218 |
$5K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
57 |
$747.17 |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
99 |
$674.77 |