| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
378 |
221 |
$42K |
| D1110 |
Prophylaxis - adult |
693 |
688 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
162 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
733 |
728 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
135 |
99 |
$16K |
| D0274 |
Bitewings - four radiographic images |
338 |
335 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
252 |
$12K |
| D0330 |
Panoramic radiographic image |
142 |
141 |
$9K |
| D1120 |
Prophylaxis - child |
187 |
187 |
$8K |
| D1206 |
Topical application of fluoride varnish |
510 |
506 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
95 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
315 |
312 |
$4K |
| D0272 |
Bitewings - two radiographic images |
80 |
80 |
$2K |
| D1330 |
|
440 |
439 |
$2K |
| D0603 |
|
196 |
196 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
61 |
$1K |
| D0270 |
|
58 |
58 |
$849.61 |
| D0602 |
|
43 |
43 |
$330.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
16 |
$212.00 |
| D1999 |
|
30 |
27 |
$0.00 |