| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
95 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
75 |
$5K |
| D1110 |
Prophylaxis - adult |
235 |
235 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
213 |
213 |
$4K |
| D2954 |
|
78 |
63 |
$4K |
| D0330 |
Panoramic radiographic image |
166 |
166 |
$3K |
| D4341 |
|
82 |
30 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
148 |
$3K |
| D1120 |
Prophylaxis - child |
119 |
119 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
116 |
$2K |
| D0274 |
Bitewings - four radiographic images |
229 |
229 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
390 |
378 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
327 |
325 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
108 |
$864.00 |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$315.00 |