| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
244 |
147 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
856 |
826 |
$21K |
| D1110 |
Prophylaxis - adult |
595 |
563 |
$21K |
| D0274 |
Bitewings - four radiographic images |
250 |
238 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
412 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
378 |
286 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
77 |
$3K |
| D1120 |
Prophylaxis - child |
125 |
119 |
$3K |
| D0330 |
Panoramic radiographic image |
63 |
59 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
173 |
169 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$874.32 |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$453.06 |