| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
125 |
$639.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
394 |
$456.00 |
| D0274 |
Bitewings - four radiographic images |
228 |
204 |
$232.00 |
| D0140 |
Limited oral evaluation - problem focused |
71 |
71 |
$105.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$84.00 |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
189 |
$78.00 |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
71 |
$58.00 |
| D0603 |
|
235 |
214 |
$55.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$52.00 |
| D1120 |
Prophylaxis - child |
35 |
35 |
$40.00 |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$19.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
110 |
$18.00 |
| D1330 |
|
452 |
412 |
$10.00 |
| D1310 |
|
442 |
407 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
19 |
19 |
$0.00 |
| D0601 |
|
13 |
12 |
$0.00 |
| D2335 |
|
29 |
12 |
$0.00 |
| D0602 |
|
75 |
66 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$0.00 |