| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
92 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
658 |
603 |
$16K |
| D1110 |
Prophylaxis - adult |
432 |
394 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
74 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
173 |
171 |
$3K |
| D0274 |
Bitewings - four radiographic images |
87 |
85 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
26 |
$943.26 |
| D0330 |
Panoramic radiographic image |
29 |
17 |
$907.70 |
| D4355 |
|
13 |
12 |
$874.64 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$336.31 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$181.20 |