| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,319 |
1,248 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
536 |
351 |
$59K |
| D0330 |
Panoramic radiographic image |
753 |
705 |
$45K |
| D0274 |
Bitewings - four radiographic images |
885 |
835 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,129 |
1,081 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,158 |
1,092 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
560 |
529 |
$19K |
| D1120 |
Prophylaxis - child |
333 |
320 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
286 |
265 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
681 |
625 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
38 |
$6K |
| D1351 |
Sealant - per tooth |
89 |
12 |
$3K |