| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
169 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
492 |
487 |
$15K |
| D1120 |
Prophylaxis - child |
212 |
210 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
353 |
336 |
$10K |
| D0330 |
Panoramic radiographic image |
272 |
260 |
$9K |
| D1110 |
Prophylaxis - adult |
180 |
180 |
$9K |
| D0274 |
Bitewings - four radiographic images |
266 |
260 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
749 |
697 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
53 |
$5K |
| D1206 |
Topical application of fluoride varnish |
240 |
237 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
610 |
532 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$1K |
| D0272 |
Bitewings - two radiographic images |
53 |
52 |
$1K |
| D4342 |
|
13 |
13 |
$897.00 |
| D1999 |
|
19 |
17 |
$0.00 |