| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
164 |
$43K |
| D1110 |
Prophylaxis - adult |
603 |
599 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
378 |
375 |
$21K |
| D1206 |
Topical application of fluoride varnish |
580 |
579 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
77 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
232 |
$11K |
| D0274 |
Bitewings - four radiographic images |
400 |
400 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
304 |
$10K |
| D0330 |
Panoramic radiographic image |
164 |
163 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
661 |
625 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
16 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
452 |
436 |
$4K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$684.60 |
| D1330 |
|
12 |
12 |
$86.40 |