| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
373 |
142 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
84 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
341 |
312 |
$8K |
| D1110 |
Prophylaxis - adult |
175 |
162 |
$5K |
| D0274 |
Bitewings - four radiographic images |
315 |
292 |
$3K |
| D2330 |
|
79 |
30 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
381 |
334 |
$2K |
| D1206 |
Topical application of fluoride varnish |
197 |
165 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
41 |
$986.24 |
| D0140 |
Limited oral evaluation - problem focused |
39 |
28 |
$537.77 |
| D0230 |
Intraoral - periapical each additional radiographic image |
306 |
254 |
$475.92 |
| D0120 |
Periodic oral evaluation - established patient |
25 |
24 |
$448.26 |
| D0190 |
|
49 |
46 |
$0.00 |
| D1330 |
|
35 |
32 |
$0.00 |