| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
79 |
$27K |
| D1110 |
Prophylaxis - adult |
423 |
409 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
557 |
434 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
225 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
462 |
447 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
43 |
$11K |
| D0330 |
Panoramic radiographic image |
187 |
176 |
$8K |
| D0274 |
Bitewings - four radiographic images |
232 |
221 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
145 |
121 |
$2K |