| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
221 |
$19K |
| D1110 |
Prophylaxis - adult |
383 |
383 |
$12K |
| D3310 |
|
31 |
14 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
93 |
64 |
$6K |
| D1206 |
Topical application of fluoride varnish |
423 |
423 |
$6K |
| D2950 |
|
80 |
65 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
80 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
247 |
$6K |
| D0274 |
Bitewings - four radiographic images |
304 |
304 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
108 |
106 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
223 |
223 |
$3K |
| D2335 |
|
39 |
16 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
532 |
356 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
106 |
102 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
417 |
416 |
$2K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$2K |
| D0350 |
|
112 |
112 |
$1K |
| D1320 |
|
12 |
12 |
$165.00 |