| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
515 |
277 |
$3K |
| D1110 |
Prophylaxis - adult |
529 |
527 |
$2K |
| D1206 |
Topical application of fluoride varnish |
1,027 |
1,008 |
$1K |
| D1120 |
Prophylaxis - child |
392 |
385 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
862 |
845 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
71 |
$728.00 |
| D0220 |
Intraoral - periapical first radiographic image |
755 |
732 |
$638.13 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
132 |
$570.00 |
| D0274 |
Bitewings - four radiographic images |
346 |
341 |
$466.53 |
| D0140 |
Limited oral evaluation - problem focused |
179 |
174 |
$423.05 |
| D0230 |
Intraoral - periapical each additional radiographic image |
653 |
576 |
$334.56 |
| D4910 |
|
144 |
143 |
$280.00 |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$174.00 |
| D1999 |
|
38 |
33 |
$98.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$84.00 |
| D0330 |
Panoramic radiographic image |
42 |
40 |
$0.00 |
| D2332 |
|
17 |
12 |
$0.00 |
| D1330 |
|
62 |
62 |
$0.00 |