| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
148 |
74 |
$13K |
| D1110 |
Prophylaxis - adult |
202 |
199 |
$8K |
| D1206 |
Topical application of fluoride varnish |
450 |
437 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
149 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
25 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
301 |
299 |
$3K |
| D1120 |
Prophylaxis - child |
127 |
125 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$988.93 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$502.32 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
37 |
$357.76 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
12 |
$273.13 |