| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
590 |
385 |
$45K |
| D1110 |
Prophylaxis - adult |
746 |
740 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
882 |
875 |
$18K |
| D0274 |
Bitewings - four radiographic images |
619 |
613 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
343 |
$10K |
| D1206 |
Topical application of fluoride varnish |
446 |
444 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
84 |
$8K |
| D1120 |
Prophylaxis - child |
231 |
231 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
86 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
427 |
420 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$947.65 |
| D4910 |
|
13 |
13 |
$718.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
45 |
$371.91 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$249.46 |
| D0601 |
|
41 |
40 |
$85.00 |