| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
589 |
444 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,301 |
1,232 |
$1K |
| D0274 |
Bitewings - four radiographic images |
798 |
759 |
$585.63 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
175 |
135 |
$280.00 |
| D0220 |
Intraoral - periapical first radiographic image |
517 |
486 |
$279.00 |
| D0210 |
Intraoral - complete series of radiographic images |
242 |
222 |
$232.00 |
| D0140 |
Limited oral evaluation - problem focused |
349 |
332 |
$210.00 |
| D1120 |
Prophylaxis - child |
347 |
325 |
$200.00 |
| D1206 |
Topical application of fluoride varnish |
424 |
404 |
$171.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
51 |
$168.00 |
| D0603 |
|
562 |
537 |
$121.00 |
| D0120 |
Periodic oral evaluation - established patient |
218 |
208 |
$84.00 |
| D0602 |
|
218 |
203 |
$44.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
89 |
$27.00 |
| D0272 |
Bitewings - two radiographic images |
90 |
83 |
$20.00 |
| D1310 |
|
1,116 |
1,055 |
$0.00 |
| D1330 |
|
1,209 |
1,145 |
$0.00 |
| D0601 |
|
49 |
43 |
$0.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$0.00 |