| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
423 |
199 |
$19K |
| D0330 |
Panoramic radiographic image |
498 |
460 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
355 |
123 |
$16K |
| D1110 |
Prophylaxis - adult |
447 |
421 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
880 |
844 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
465 |
$12K |
| D1120 |
Prophylaxis - child |
563 |
547 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
683 |
661 |
$9K |
| D0274 |
Bitewings - four radiographic images |
887 |
831 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
223 |
193 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
29 |
$3K |
| D0350 |
|
140 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
543 |
482 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
873 |
260 |
$980.00 |
| D0272 |
Bitewings - two radiographic images |
61 |
59 |
$460.00 |