| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
639 |
328 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,638 |
1,559 |
$41K |
| D1110 |
Prophylaxis - adult |
961 |
925 |
$34K |
| D1120 |
Prophylaxis - child |
969 |
934 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,371 |
1,288 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
81 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
259 |
$11K |
| D0274 |
Bitewings - four radiographic images |
334 |
315 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
43 |
$10K |
| D0330 |
Panoramic radiographic image |
194 |
171 |
$9K |
| D0272 |
Bitewings - two radiographic images |
274 |
256 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
221 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$2K |
| D1206 |
Topical application of fluoride varnish |
67 |
66 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
52 |
$713.53 |