| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
29 |
$12K |
| D1110 |
Prophylaxis - adult |
128 |
128 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
146 |
$8K |
| D0330 |
Panoramic radiographic image |
94 |
94 |
$4K |
| D0274 |
Bitewings - four radiographic images |
140 |
140 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
50 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
81 |
81 |
$3K |
| D1206 |
Topical application of fluoride varnish |
92 |
91 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
165 |
$2K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
137 |
136 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$626.00 |
| D1330 |
|
31 |
31 |
$186.00 |