| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
406 |
221 |
$55K |
| D1110 |
Prophylaxis - adult |
689 |
689 |
$45K |
| D1206 |
Topical application of fluoride varnish |
958 |
958 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
651 |
651 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
318 |
318 |
$18K |
| D0330 |
Panoramic radiographic image |
361 |
361 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
95 |
67 |
$16K |
| D0274 |
Bitewings - four radiographic images |
586 |
586 |
$14K |
| D1120 |
Prophylaxis - child |
250 |
250 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
196 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
425 |
421 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
257 |
257 |
$2K |
| D1330 |
|
177 |
177 |
$1K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$753.45 |