| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
502 |
190 |
$37K |
| D1110 |
Prophylaxis - adult |
989 |
972 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
426 |
154 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
326 |
321 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,784 |
783 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
876 |
864 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
338 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,028 |
937 |
$9K |
| D0274 |
Bitewings - four radiographic images |
427 |
419 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
426 |
420 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
162 |
158 |
$4K |
| D9994 |
|
827 |
813 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
38 |
$2K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D9630 |
|
119 |
118 |
$619.92 |
| D1206 |
Topical application of fluoride varnish |
25 |
23 |
$519.75 |