| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
467 |
249 |
$49K |
| D1110 |
Prophylaxis - adult |
932 |
891 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
829 |
708 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,928 |
1,715 |
$27K |
| D0330 |
Panoramic radiographic image |
829 |
711 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,966 |
951 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
838 |
817 |
$21K |
| D0274 |
Bitewings - four radiographic images |
809 |
755 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
548 |
510 |
$18K |
| D1120 |
Prophylaxis - child |
318 |
280 |
$8K |
| D1206 |
Topical application of fluoride varnish |
442 |
429 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
164 |
97 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
97 |
72 |
$1K |