| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
879 |
878 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
446 |
289 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
808 |
807 |
$20K |
| D1206 |
Topical application of fluoride varnish |
671 |
666 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
94 |
$7K |
| D0274 |
Bitewings - four radiographic images |
623 |
621 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
243 |
243 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
92 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
749 |
744 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
818 |
814 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
17 |
$2K |
| D0603 |
|
27 |
26 |
$140.00 |