| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
563 |
285 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
612 |
521 |
$24K |
| D1110 |
Prophylaxis - adult |
594 |
537 |
$21K |
| D0274 |
Bitewings - four radiographic images |
562 |
518 |
$17K |
| D0330 |
Panoramic radiographic image |
333 |
301 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
719 |
658 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
306 |
283 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
102 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
108 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
31 |
30 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
44 |
$957.16 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
12 |
$590.85 |