| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
652 |
319 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,507 |
1,413 |
$26K |
| D1120 |
Prophylaxis - child |
825 |
784 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,066 |
998 |
$20K |
| D1110 |
Prophylaxis - adult |
514 |
464 |
$17K |
| D0330 |
Panoramic radiographic image |
234 |
193 |
$9K |
| D0272 |
Bitewings - two radiographic images |
404 |
384 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
58 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
187 |
$5K |
| D0274 |
Bitewings - four radiographic images |
278 |
240 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
53 |
$582.45 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
14 |
$365.40 |