| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
311 |
156 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
333 |
321 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
118 |
$4K |
| D0330 |
Panoramic radiographic image |
169 |
167 |
$3K |
| D1110 |
Prophylaxis - adult |
127 |
125 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
41 |
$2K |
| D1120 |
Prophylaxis - child |
202 |
196 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
436 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
427 |
416 |
$647.77 |
| D0274 |
Bitewings - four radiographic images |
326 |
315 |
$345.44 |
| D1206 |
Topical application of fluoride varnish |
105 |
100 |
$66.58 |
| D1208 |
Topical application of fluoride, excluding varnish |
286 |
280 |
$58.78 |
| D1330 |
|
405 |
396 |
$22.40 |
| D0272 |
Bitewings - two radiographic images |
20 |
19 |
$0.00 |