| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
123 |
$26K |
| D1120 |
Prophylaxis - child |
621 |
602 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
735 |
712 |
$22K |
| D1206 |
Topical application of fluoride varnish |
804 |
746 |
$16K |
| D1110 |
Prophylaxis - adult |
236 |
225 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
255 |
231 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
321 |
321 |
$10K |
| D0330 |
Panoramic radiographic image |
115 |
113 |
$9K |
| D0272 |
Bitewings - two radiographic images |
143 |
142 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
98 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
46 |
44 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
68 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
13 |
$113.00 |