| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
414 |
408 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
91 |
$11K |
| D0330 |
Panoramic radiographic image |
301 |
296 |
$10K |
| D0274 |
Bitewings - four radiographic images |
283 |
279 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
55 |
$5K |
| D1110 |
Prophylaxis - adult |
102 |
102 |
$3K |
| D1120 |
Prophylaxis - child |
73 |
71 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
114 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
46 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
73 |
$670.34 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$321.84 |