| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,510 |
403 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,744 |
424 |
$1K |
| D2394 |
|
1,021 |
366 |
$662.70 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
678 |
275 |
$361.74 |
| D1110 |
Prophylaxis - adult |
583 |
439 |
$147.58 |
| D0330 |
Panoramic radiographic image |
239 |
145 |
$123.80 |
| D0274 |
Bitewings - four radiographic images |
540 |
369 |
$94.85 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
488 |
379 |
$92.56 |
| D1206 |
Topical application of fluoride varnish |
855 |
636 |
$59.10 |
| D0220 |
Intraoral - periapical first radiographic image |
742 |
525 |
$41.19 |
| D0140 |
Limited oral evaluation - problem focused |
282 |
183 |
$39.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
642 |
409 |
$33.60 |
| D0120 |
Periodic oral evaluation - established patient |
185 |
127 |
$21.72 |
| D1120 |
Prophylaxis - child |
41 |
28 |
$0.00 |
| D9951 |
|
20 |
13 |
$0.00 |
| D2330 |
|
80 |
27 |
$0.00 |
| D1320 |
|
175 |
165 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
221 |
200 |
$0.00 |