| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
614 |
396 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,223 |
1,195 |
$30K |
| D1110 |
Prophylaxis - adult |
960 |
940 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,176 |
1,157 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
382 |
199 |
$20K |
| D0330 |
Panoramic radiographic image |
604 |
588 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
524 |
511 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,586 |
1,546 |
$17K |
| D1120 |
Prophylaxis - child |
713 |
697 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
227 |
217 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
202 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
44 |
$1K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$542.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
25 |
$208.00 |