| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
550 |
549 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
242 |
131 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
338 |
337 |
$19K |
| D1206 |
Topical application of fluoride varnish |
608 |
604 |
$16K |
| D0330 |
Panoramic radiographic image |
285 |
284 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
339 |
338 |
$11K |
| D0274 |
Bitewings - four radiographic images |
361 |
360 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
36 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
377 |
367 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
50 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
196 |
196 |
$1K |