| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
41 |
$4K |
| D0330 |
Panoramic radiographic image |
61 |
60 |
$2K |
| D1110 |
Prophylaxis - adult |
58 |
57 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
81 |
80 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
17 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
43 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$984.20 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$767.72 |
| D0274 |
Bitewings - four radiographic images |
78 |
76 |
$680.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$420.00 |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
115 |
$345.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
85 |
$310.00 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$220.00 |