| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
564 |
562 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
147 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
382 |
379 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
127 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
153 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
50 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
155 |
155 |
$2K |