| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
552 |
224 |
$47K |
| D1110 |
Prophylaxis - adult |
1,102 |
985 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,489 |
1,336 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
318 |
123 |
$22K |
| D1120 |
Prophylaxis - child |
803 |
707 |
$18K |
| D0274 |
Bitewings - four radiographic images |
535 |
461 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
922 |
790 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
221 |
$9K |
| D1206 |
Topical application of fluoride varnish |
437 |
421 |
$7K |
| D0272 |
Bitewings - two radiographic images |
117 |
114 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$619.52 |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
41 |
$595.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$437.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
12 |
$274.56 |
| D1999 |
|
335 |
319 |
$0.00 |