| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
846 |
501 |
$67K |
| D1110 |
Prophylaxis - adult |
1,213 |
1,210 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,654 |
1,649 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
293 |
217 |
$24K |
| D0274 |
Bitewings - four radiographic images |
985 |
985 |
$23K |
| D1120 |
Prophylaxis - child |
571 |
570 |
$17K |
| D1206 |
Topical application of fluoride varnish |
933 |
929 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
175 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
371 |
371 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
582 |
540 |
$5K |
| D0272 |
Bitewings - two radiographic images |
154 |
154 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
93 |
$3K |
| D0601 |
|
199 |
199 |
$990.00 |
| D4910 |
|
13 |
13 |
$718.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
78 |
$704.50 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$619.19 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$548.87 |
| D0602 |
|
45 |
45 |
$215.00 |