| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
503 |
260 |
$68K |
| D1206 |
Topical application of fluoride varnish |
1,200 |
1,186 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
288 |
179 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
569 |
493 |
$27K |
| D1110 |
Prophylaxis - adult |
360 |
359 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
259 |
$14K |
| D1120 |
Prophylaxis - child |
291 |
290 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
423 |
$13K |
| D2940 |
|
178 |
61 |
$9K |
| D0274 |
Bitewings - four radiographic images |
341 |
336 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
496 |
414 |
$6K |
| D3120 |
|
157 |
69 |
$5K |
| D0330 |
Panoramic radiographic image |
104 |
96 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
53 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
107 |
$1K |
| D1330 |
|
133 |
133 |
$890.40 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$196.92 |