| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
518 |
506 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
195 |
101 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
542 |
529 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
204 |
$11K |
| D0274 |
Bitewings - four radiographic images |
409 |
394 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
268 |
$8K |
| D0330 |
Panoramic radiographic image |
155 |
149 |
$7K |
| D2750 |
|
16 |
12 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
27 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
404 |
381 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
54 |
$3K |