| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
190 |
106 |
$25K |
| D1120 |
Prophylaxis - child |
448 |
446 |
$20K |
| D0330 |
Panoramic radiographic image |
265 |
261 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
443 |
421 |
$15K |
| D1110 |
Prophylaxis - adult |
209 |
204 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
378 |
376 |
$10K |
| D0272 |
Bitewings - two radiographic images |
267 |
265 |
$7K |
| D1206 |
Topical application of fluoride varnish |
166 |
164 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
91 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
37 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
60 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$919.10 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$180.00 |