| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
994 |
289 |
$31K |
| D1110 |
Prophylaxis - adult |
413 |
407 |
$16K |
| D0330 |
Panoramic radiographic image |
236 |
228 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
114 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
577 |
573 |
$10K |
| D1206 |
Topical application of fluoride varnish |
628 |
619 |
$9K |
| D0274 |
Bitewings - four radiographic images |
346 |
337 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
295 |
257 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
676 |
580 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
152 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
36 |
$4K |
| D2330 |
|
60 |
28 |
$3K |
| D2140 |
|
34 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
96 |
$812.13 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$345.15 |
| D1330 |
|
12 |
12 |
$64.62 |
| D9985 |
|
17 |
16 |
$0.00 |