| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
404 |
153 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
456 |
444 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
357 |
$12K |
| D0330 |
Panoramic radiographic image |
458 |
446 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
27 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$4K |
| D1110 |
Prophylaxis - adult |
81 |
80 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
462 |
445 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
278 |
271 |
$2K |
| D0274 |
Bitewings - four radiographic images |
683 |
662 |
$2K |
| D1330 |
|
537 |
518 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,103 |
1,072 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,217 |
955 |
$977.16 |
| D1120 |
Prophylaxis - child |
186 |
176 |
$847.80 |
| D4346 |
|
14 |
13 |
$626.08 |
| D0601 |
|
118 |
115 |
$142.26 |
| D0272 |
Bitewings - two radiographic images |
60 |
59 |
$13.44 |
| D4921 |
|
46 |
17 |
$0.00 |