| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
95 |
$19K |
| D1110 |
Prophylaxis - adult |
373 |
373 |
$18K |
| D0274 |
Bitewings - four radiographic images |
592 |
592 |
$16K |
| D0330 |
Panoramic radiographic image |
386 |
386 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
331 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
262 |
261 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
570 |
561 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
25 |
$6K |
| D1206 |
Topical application of fluoride varnish |
330 |
330 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
190 |
168 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
63 |
$1K |
| D1120 |
Prophylaxis - child |
36 |
36 |
$1K |