| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
153 |
$51K |
| D1110 |
Prophylaxis - adult |
591 |
487 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
498 |
411 |
$25K |
| D0274 |
Bitewings - four radiographic images |
400 |
315 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
871 |
726 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
421 |
367 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
202 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
465 |
416 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
570 |
444 |
$10K |
| D1120 |
Prophylaxis - child |
190 |
162 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
24 |
$6K |
| D0330 |
Panoramic radiographic image |
33 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
23 |
$2K |
| D0272 |
Bitewings - two radiographic images |
36 |
26 |
$855.12 |