| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
158 |
$16K |
| D1110 |
Prophylaxis - adult |
327 |
324 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
431 |
429 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
72 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
124 |
$6K |
| D1120 |
Prophylaxis - child |
298 |
297 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
218 |
217 |
$6K |
| D1206 |
Topical application of fluoride varnish |
315 |
314 |
$5K |
| D0274 |
Bitewings - four radiographic images |
222 |
221 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
198 |
196 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$509.52 |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
77 |
$350.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$293.54 |