| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
896 |
425 |
$13K |
| D1110 |
Prophylaxis - adult |
833 |
816 |
$10K |
| D0330 |
Panoramic radiographic image |
212 |
211 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
702 |
684 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
801 |
782 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
380 |
277 |
$8K |
| D0274 |
Bitewings - four radiographic images |
727 |
710 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
142 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
475 |
468 |
$624.79 |
| D4341 |
|
63 |
26 |
$0.00 |
| D2331 |
|
51 |
27 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
94 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
171 |
170 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
453 |
235 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
55 |
55 |
$0.00 |