| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
24 |
$4K |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$3K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$2K |
| D1206 |
Topical application of fluoride varnish |
77 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
51 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
44 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
23 |
23 |
$767.00 |