| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
113 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
178 |
67 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
251 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
187 |
184 |
$7K |
| D1110 |
Prophylaxis - adult |
84 |
81 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
106 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
40 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
94 |
91 |
$624.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$480.00 |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$420.00 |
| D0274 |
Bitewings - four radiographic images |
57 |
55 |
$58.00 |
| D1330 |
|
24 |
23 |
$0.00 |