| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
751 |
394 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
598 |
589 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,070 |
550 |
$27K |
| D1110 |
Prophylaxis - adult |
735 |
732 |
$12K |
| D0274 |
Bitewings - four radiographic images |
512 |
511 |
$9K |
| D0330 |
Panoramic radiographic image |
258 |
256 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
303 |
161 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
225 |
225 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
893 |
883 |
$3K |
| D1206 |
Topical application of fluoride varnish |
479 |
475 |
$817.91 |
| D1330 |
|
443 |
439 |
$477.67 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
36 |
$241.00 |
| D0220 |
Intraoral - periapical first radiographic image |
644 |
639 |
$228.57 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$185.05 |
| D0230 |
Intraoral - periapical each additional radiographic image |
693 |
576 |
$129.24 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$27.00 |