| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
98 |
$18K |
| D1120 |
Prophylaxis - child |
295 |
278 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
229 |
226 |
$10K |
| D0274 |
Bitewings - four radiographic images |
260 |
258 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
41 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
299 |
292 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
344 |
339 |
$5K |
| D1110 |
Prophylaxis - adult |
134 |
132 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
182 |
182 |
$4K |
| D1206 |
Topical application of fluoride varnish |
255 |
255 |
$4K |
| D0272 |
Bitewings - two radiographic images |
126 |
125 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
76 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D9920 |
|
14 |
14 |
$796.88 |
| D0330 |
Panoramic radiographic image |
15 |
13 |
$506.00 |