| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
620 |
322 |
$46K |
| D1110 |
Prophylaxis - adult |
966 |
964 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
444 |
241 |
$18K |
| D0330 |
Panoramic radiographic image |
227 |
226 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
824 |
819 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
120 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
576 |
570 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
54 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,055 |
1,047 |
$2K |
| D1330 |
|
1,251 |
1,242 |
$2K |
| D2332 |
|
29 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
40 |
39 |
$712.88 |
| D0140 |
Limited oral evaluation - problem focused |
71 |
71 |
$705.15 |
| D0274 |
Bitewings - four radiographic images |
773 |
769 |
$547.00 |
| D1999 |
|
31 |
27 |
$287.69 |
| D0230 |
Intraoral - periapical each additional radiographic image |
877 |
871 |
$54.60 |
| D0220 |
Intraoral - periapical first radiographic image |
960 |
950 |
$51.62 |
| D0272 |
Bitewings - two radiographic images |
290 |
288 |
$0.00 |