| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
286 |
203 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
137 |
$27K |
| D0330 |
Panoramic radiographic image |
272 |
271 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
333 |
330 |
$22K |
| D1206 |
Topical application of fluoride varnish |
499 |
490 |
$19K |
| D1120 |
Prophylaxis - child |
374 |
373 |
$19K |
| D0272 |
Bitewings - two radiographic images |
287 |
287 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
273 |
269 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
428 |
421 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
141 |
$10K |
| D0274 |
Bitewings - four radiographic images |
164 |
162 |
$7K |
| D1110 |
Prophylaxis - adult |
96 |
95 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
165 |
114 |
$5K |