| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
42 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
28 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
170 |
166 |
$4K |
| D0274 |
Bitewings - four radiographic images |
116 |
113 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
207 |
200 |
$3K |
| D1110 |
Prophylaxis - adult |
66 |
63 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
220 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
230 |
212 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
42 |
$1K |
| D0330 |
Panoramic radiographic image |
46 |
43 |
$701.18 |
| D0603 |
|
267 |
261 |
$0.00 |