| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
165 |
$17K |
| D1110 |
Prophylaxis - adult |
239 |
228 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
100 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
285 |
273 |
$7K |
| D1206 |
Topical application of fluoride varnish |
286 |
274 |
$6K |
| D1120 |
Prophylaxis - child |
122 |
122 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
37 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
117 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
313 |
283 |
$3K |
| D0274 |
Bitewings - four radiographic images |
102 |
101 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
94 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
183 |
164 |
$1K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$520.77 |