| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
151 |
151 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
28 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$3K |
| D0274 |
Bitewings - four radiographic images |
127 |
127 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
124 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
79 |
79 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
210 |
207 |
$2K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
43 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
141 |
140 |
$1K |