| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
202 |
126 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
116 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
440 |
$18K |
| D0274 |
Bitewings - four radiographic images |
355 |
344 |
$11K |
| D1110 |
Prophylaxis - adult |
301 |
297 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
947 |
459 |
$10K |
| D4355 |
|
142 |
139 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
670 |
634 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
323 |
313 |
$7K |
| D0330 |
Panoramic radiographic image |
140 |
133 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
85 |
45 |
$7K |
| D1206 |
Topical application of fluoride varnish |
358 |
344 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
100 |
$4K |
| D2394 |
|
21 |
14 |
$3K |
| D2335 |
|
21 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
46 |
45 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$270.90 |