| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
494 |
383 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
458 |
310 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
491 |
491 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
293 |
293 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,499 |
380 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
307 |
301 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
672 |
656 |
$2K |
| D1206 |
Topical application of fluoride varnish |
419 |
418 |
$2K |
| D0274 |
Bitewings - four radiographic images |
282 |
282 |
$2K |
| D0603 |
|
612 |
611 |
$2K |
| D0330 |
Panoramic radiographic image |
194 |
194 |
$1K |
| D4341 |
|
63 |
50 |
$990.00 |
| D1120 |
Prophylaxis - child |
107 |
107 |
$960.00 |
| D1110 |
Prophylaxis - adult |
98 |
98 |
$799.00 |
| D0120 |
Periodic oral evaluation - established patient |
177 |
177 |
$588.00 |
| D0270 |
|
157 |
152 |
$374.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
18 |
$336.00 |
| D1310 |
|
819 |
806 |
$60.00 |
| D1320 |
|
25 |
25 |
$60.00 |
| D1330 |
|
828 |
814 |
$40.00 |
| D1354 |
|
72 |
25 |
$20.00 |
| D0602 |
|
13 |
13 |
$11.00 |