| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
58 |
$7K |
| D1110 |
Prophylaxis - adult |
97 |
96 |
$4K |
| D1120 |
Prophylaxis - child |
88 |
84 |
$4K |
| D0330 |
Panoramic radiographic image |
70 |
66 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
98 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
91 |
87 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
114 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
81 |
80 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
63 |
$318.11 |
| D1206 |
Topical application of fluoride varnish |
21 |
19 |
$258.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$214.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
45 |
$154.05 |