| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
729 |
541 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
923 |
923 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
305 |
266 |
$11K |
| D1120 |
Prophylaxis - child |
507 |
507 |
$10K |
| D1110 |
Prophylaxis - adult |
495 |
495 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
300 |
298 |
$6K |
| D0274 |
Bitewings - four radiographic images |
561 |
561 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
633 |
633 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
848 |
846 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
442 |
$3K |
| D0272 |
Bitewings - two radiographic images |
315 |
315 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
32 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$300.00 |
| D0270 |
|
56 |
56 |
$168.00 |
| D1999 |
|
32 |
25 |
$0.00 |