| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
53 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
184 |
183 |
$10K |
| D1110 |
Prophylaxis - adult |
142 |
141 |
$9K |
| D1206 |
Topical application of fluoride varnish |
126 |
126 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
198 |
193 |
$2K |
| D0274 |
Bitewings - four radiographic images |
93 |
92 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
159 |
157 |
$1K |