| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
123 |
$43K |
| D1110 |
Prophylaxis - adult |
563 |
543 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
617 |
603 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
743 |
725 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
31 |
$15K |
| D0274 |
Bitewings - four radiographic images |
533 |
520 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
140 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
149 |
144 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
507 |
486 |
$6K |
| D1120 |
Prophylaxis - child |
110 |
110 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
364 |
360 |
$3K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$2K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$410.25 |
| D1330 |
|
37 |
37 |
$250.80 |