| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
97 |
$16K |
| D1110 |
Prophylaxis - adult |
294 |
276 |
$10K |
| D0330 |
Panoramic radiographic image |
193 |
176 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
62 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
180 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
275 |
251 |
$6K |
| D0274 |
Bitewings - four radiographic images |
220 |
193 |
$5K |
| D1120 |
Prophylaxis - child |
184 |
160 |
$4K |
| D1206 |
Topical application of fluoride varnish |
205 |
181 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
129 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
32 |
$631.77 |