| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
200 |
101 |
$27K |
| D1110 |
Prophylaxis - adult |
302 |
297 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
193 |
$11K |
| D0330 |
Panoramic radiographic image |
174 |
170 |
$8K |
| D1206 |
Topical application of fluoride varnish |
282 |
277 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
25 |
$6K |
| D0274 |
Bitewings - four radiographic images |
218 |
213 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
121 |
121 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
197 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
105 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$1K |
| D1120 |
Prophylaxis - child |
18 |
18 |
$834.30 |
| D1330 |
|
28 |
28 |
$168.00 |