| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
139 |
82 |
$18K |
| D1120 |
Prophylaxis - child |
277 |
272 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
146 |
145 |
$10K |
| D1206 |
Topical application of fluoride varnish |
335 |
328 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
174 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
44 |
$7K |
| D0330 |
Panoramic radiographic image |
87 |
85 |
$7K |
| D0272 |
Bitewings - two radiographic images |
167 |
163 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
148 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
199 |
195 |
$4K |
| D0274 |
Bitewings - four radiographic images |
59 |
57 |
$3K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$2K |