| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
136 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
937 |
619 |
$28K |
| D1110 |
Prophylaxis - adult |
262 |
249 |
$10K |
| D0330 |
Panoramic radiographic image |
170 |
154 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
617 |
377 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
212 |
207 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
39 |
$5K |
| D1206 |
Topical application of fluoride varnish |
304 |
291 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
330 |
233 |
$3K |
| D1120 |
Prophylaxis - child |
122 |
116 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
222 |
182 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
25 |
$2K |
| D0274 |
Bitewings - four radiographic images |
66 |
64 |
$2K |
| D0272 |
Bitewings - two radiographic images |
41 |
38 |
$685.89 |