| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
444 |
437 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
118 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
324 |
$7K |
| D0274 |
Bitewings - four radiographic images |
229 |
225 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
62 |
$6K |
| D0330 |
Panoramic radiographic image |
134 |
133 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
162 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
275 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
190 |
183 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
63 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$924.48 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$588.50 |
| D1120 |
Prophylaxis - child |
16 |
14 |
$494.34 |
| D0602 |
|
39 |
38 |
$360.00 |
| D1330 |
|
49 |
48 |
$256.80 |
| D0272 |
Bitewings - two radiographic images |
15 |
13 |
$250.38 |