| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
648 |
307 |
$51K |
| D1110 |
Prophylaxis - adult |
1,094 |
1,078 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
256 |
135 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
857 |
853 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
913 |
819 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
390 |
378 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
233 |
104 |
$9K |
| D0274 |
Bitewings - four radiographic images |
386 |
377 |
$5K |
| D0330 |
Panoramic radiographic image |
185 |
180 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
85 |
83 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
103 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
284 |
143 |
$2K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$589.69 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$536.00 |
| D0180 |
|
33 |
33 |
$135.32 |