| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
615 |
231 |
$85K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
311 |
128 |
$51K |
| D1110 |
Prophylaxis - adult |
962 |
956 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
899 |
895 |
$21K |
| D0274 |
Bitewings - four radiographic images |
521 |
517 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
52 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
863 |
847 |
$11K |
| D1206 |
Topical application of fluoride varnish |
421 |
421 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
193 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
251 |
250 |
$6K |
| D0330 |
Panoramic radiographic image |
107 |
106 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
54 |
$2K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$535.96 |