| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
823 |
454 |
$92K |
| D1110 |
Prophylaxis - adult |
1,701 |
1,701 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
1,880 |
1,880 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,498 |
1,498 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
384 |
265 |
$34K |
| D1120 |
Prophylaxis - child |
709 |
709 |
$26K |
| D0274 |
Bitewings - four radiographic images |
919 |
919 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
518 |
518 |
$22K |
| D0330 |
Panoramic radiographic image |
325 |
325 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
57 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
382 |
375 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
93 |
$1K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$461.25 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$418.73 |