| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
72 |
$18K |
| D1110 |
Prophylaxis - adult |
286 |
262 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
416 |
396 |
$11K |
| D1206 |
Topical application of fluoride varnish |
312 |
299 |
$8K |
| D1120 |
Prophylaxis - child |
169 |
166 |
$7K |
| D0274 |
Bitewings - four radiographic images |
159 |
147 |
$5K |
| D0272 |
Bitewings - two radiographic images |
185 |
180 |
$5K |
| D0330 |
Panoramic radiographic image |
64 |
61 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
60 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
109 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
38 |
$376.54 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$362.49 |