| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,085 |
1,039 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
400 |
163 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,193 |
1,161 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
798 |
788 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
540 |
503 |
$14K |
| D0330 |
Panoramic radiographic image |
350 |
332 |
$12K |
| D0274 |
Bitewings - four radiographic images |
461 |
442 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
51 |
$7K |
| D1120 |
Prophylaxis - child |
197 |
186 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
188 |
173 |
$3K |