| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
67 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
186 |
$5K |
| D1110 |
Prophylaxis - adult |
82 |
77 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
30 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
66 |
61 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
63 |
$900.00 |
| D1120 |
Prophylaxis - child |
49 |
47 |
$880.00 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
16 |
$338.70 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$65.00 |