| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
411 |
151 |
$37K |
| D1110 |
Prophylaxis - adult |
319 |
304 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
58 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
69 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
342 |
328 |
$7K |
| D0274 |
Bitewings - four radiographic images |
193 |
186 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
159 |
$5K |
| D1206 |
Topical application of fluoride varnish |
200 |
200 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
113 |
$3K |
| D0330 |
Panoramic radiographic image |
64 |
56 |
$3K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$2K |
| D2950 |
|
13 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$629.60 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$145.34 |