| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
859 |
521 |
$92K |
| D1110 |
Prophylaxis - adult |
1,671 |
1,440 |
$88K |
| D1120 |
Prophylaxis - child |
1,762 |
1,415 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,913 |
2,353 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,324 |
1,917 |
$58K |
| D0330 |
Panoramic radiographic image |
925 |
768 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
530 |
265 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,300 |
1,103 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
919 |
739 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
633 |
566 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
752 |
214 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
88 |
$3K |
| D0272 |
Bitewings - two radiographic images |
104 |
78 |
$2K |
| D1320 |
|
33 |
30 |
$669.27 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$427.00 |
| D9986 |
|
64 |
59 |
$0.00 |
| D1999 |
|
19 |
12 |
$0.00 |