| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
176 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
162 |
162 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
144 |
106 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
260 |
$8K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
94 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
31 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$2K |
| D1206 |
Topical application of fluoride varnish |
68 |
68 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$922.96 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$748.32 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$604.10 |
| D1321 |
|
25 |
25 |
$355.50 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$242.85 |