| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
311 |
137 |
$34K |
| D1110 |
Prophylaxis - adult |
413 |
412 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
315 |
314 |
$9K |
| D0330 |
Panoramic radiographic image |
134 |
134 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
200 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
41 |
$7K |
| D1330 |
|
252 |
250 |
$7K |
| D0274 |
Bitewings - four radiographic images |
157 |
157 |
$6K |
| D1310 |
|
102 |
102 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
113 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
332 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
56 |
$4K |
| D1206 |
Topical application of fluoride varnish |
199 |
199 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
16 |
$3K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D9110 |
|
46 |
46 |
$1K |
| D0270 |
|
82 |
82 |
$1K |
| D0603 |
|
85 |
85 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$431.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
14 |
$238.20 |