| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,645 |
391 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
463 |
200 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
399 |
399 |
$11K |
| D0330 |
Panoramic radiographic image |
238 |
238 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
321 |
230 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
297 |
286 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
258 |
$4K |
| D1110 |
Prophylaxis - adult |
113 |
113 |
$4K |
| D0274 |
Bitewings - four radiographic images |
186 |
186 |
$4K |
| D1206 |
Topical application of fluoride varnish |
194 |
194 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
465 |
110 |
$2K |
| D4342 |
|
28 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
83 |
83 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
230 |
$1K |