| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
118 |
$29K |
| D1110 |
Prophylaxis - adult |
444 |
439 |
$28K |
| D1206 |
Topical application of fluoride varnish |
644 |
635 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
269 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
388 |
383 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
29 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$3K |
| D0274 |
Bitewings - four radiographic images |
129 |
128 |
$3K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$567.12 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
25 |
$246.25 |