| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
217 |
137 |
$19K |
| D0274 |
Bitewings - four radiographic images |
327 |
327 |
$11K |
| D1110 |
Prophylaxis - adult |
217 |
217 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
419 |
227 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
59 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
233 |
233 |
$7K |
| D0330 |
Panoramic radiographic image |
129 |
129 |
$7K |
| D1206 |
Topical application of fluoride varnish |
229 |
229 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
254 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$806.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$700.00 |