| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
451 |
449 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
25 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
200 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
449 |
447 |
$11K |
| D0330 |
Panoramic radiographic image |
219 |
214 |
$10K |
| D0274 |
Bitewings - four radiographic images |
292 |
288 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
119 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
412 |
407 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
381 |
377 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
42 |
42 |
$1K |