| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
711 |
710 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
905 |
904 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
949 |
946 |
$18K |
| D0274 |
Bitewings - four radiographic images |
634 |
634 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
146 |
$14K |
| D1120 |
Prophylaxis - child |
156 |
156 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
47 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
336 |
336 |
$4K |
| D0272 |
Bitewings - two radiographic images |
121 |
121 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
85 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
39 |
$882.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
16 |
$708.56 |
| D1330 |
|
807 |
807 |
$0.00 |
| D1999 |
|
1,301 |
1,237 |
$0.00 |