| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
980 |
582 |
$116K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
731 |
450 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,839 |
1,837 |
$49K |
| D1120 |
Prophylaxis - child |
1,254 |
1,254 |
$49K |
| D1110 |
Prophylaxis - adult |
739 |
738 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,500 |
1,500 |
$37K |
| D0274 |
Bitewings - four radiographic images |
840 |
839 |
$28K |
| D0240 |
|
1,358 |
683 |
$28K |
| D4355 |
|
177 |
177 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
120 |
91 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
347 |
338 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
567 |
549 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
149 |
$6K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
197 |
142 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$709.50 |