| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
149 |
$24K |
| D1110 |
Prophylaxis - adult |
427 |
425 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
487 |
487 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
86 |
$11K |
| D0274 |
Bitewings - four radiographic images |
167 |
166 |
$6K |
| D1206 |
Topical application of fluoride varnish |
308 |
307 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
26 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
225 |
$3K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |
| D1330 |
|
234 |
234 |
$975.00 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$580.00 |
| D0603 |
|
40 |
40 |
$240.00 |
| D1999 |
|
13 |
13 |
$0.00 |