| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
428 |
245 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
197 |
$32K |
| D1120 |
Prophylaxis - child |
462 |
461 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
620 |
618 |
$15K |
| D1206 |
Topical application of fluoride varnish |
512 |
511 |
$12K |
| D1110 |
Prophylaxis - adult |
287 |
284 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
60 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
648 |
$10K |
| D0274 |
Bitewings - four radiographic images |
295 |
291 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
576 |
525 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
92 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
14 |
$851.60 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$614.36 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
13 |
$494.78 |