| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
986 |
470 |
$105K |
| D1120 |
Prophylaxis - child |
1,231 |
1,228 |
$37K |
| D1110 |
Prophylaxis - adult |
784 |
784 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,952 |
1,947 |
$29K |
| D0274 |
Bitewings - four radiographic images |
784 |
784 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,074 |
1,070 |
$22K |
| D0330 |
Panoramic radiographic image |
345 |
345 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
534 |
530 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$4K |
| D0603 |
|
263 |
263 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
97 |
97 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
97 |
$1K |
| D0601 |
|
92 |
92 |
$841.80 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$792.88 |