| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
499 |
212 |
$24K |
| D1110 |
Prophylaxis - adult |
600 |
564 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
343 |
145 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
253 |
138 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
701 |
659 |
$11K |
| D0274 |
Bitewings - four radiographic images |
503 |
470 |
$9K |
| D2335 |
|
67 |
28 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
188 |
$5K |
| D1120 |
Prophylaxis - child |
268 |
250 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
351 |
328 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,016 |
913 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
905 |
754 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
122 |
$2K |
| D0330 |
Panoramic radiographic image |
52 |
45 |
$2K |
| D0350 |
|
254 |
238 |
$2K |
| D2394 |
|
20 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
105 |
100 |
$980.00 |
| D2331 |
|
23 |
15 |
$888.86 |
| D2330 |
|
27 |
14 |
$665.73 |