| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
338 |
163 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
368 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
132 |
62 |
$15K |
| D1110 |
Prophylaxis - adult |
275 |
253 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
61 |
$8K |
| D0330 |
Panoramic radiographic image |
148 |
134 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
751 |
278 |
$7K |
| D0274 |
Bitewings - four radiographic images |
229 |
207 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
359 |
319 |
$5K |
| D1120 |
Prophylaxis - child |
167 |
152 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
234 |
219 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
57 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
87 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$232.20 |